Last month, The New York Times Magazine published a comprehensive story by journalist Paul Tough, on the current state of research into Attention Deficit Hyperactivity Disorder, or ADHD. The piece reached stark and ground-breaking conclusions. To put them bluntly, there is no reliable clinical or biological basis for an ADHD diagnosis, to such an extent that the leading researchers in the field have begun to speak of viewing the suite of behaviors associated with the condition in a different light. Plus: prescription amphetamines such as Ritalin and Adderall have proved ineffective at deceasing the symptoms over the long term, do not enhance learning and may be detrimental to it, and have worrisome physical side effects.
Yet Tough, throughout the article, and in later remarks in an interview with Adam B. Kushner for his morning newsletter for The New York Times, is reluctant to reach his own conclusions, and presents the material in carefully couched language such as “most researchers I spoke with believe that stimulant medications are, on the whole, a positive thing for children with ADHD.” And: “most scientists I spoke to agreed that the condition is produced by some combination of biological and environmental forces.”
This kind of hedging is understandable given the sensitivity of the topic for the families involved, and it accurately reflects the medical rhetoric, though not the science. Scientists can believe and agree to all kinds of things that aren’t based on evidence. And they have a powerful incentives to do so — institutional inertia, the difficulty of speaking out against a popular consensus, and the financial interests of their institutions and the pharmaceutical companies, to name just a few. However, if we want to slow the flood of pills — and, most important, help American schoolchildren, especially boys — we must fight the tendency to temporize.
Tough is the author of several books on eduction and child development, and is a meticulous researcher and long-form feature writer of the highest professional standing. He spent a year compiling the story, which is worth reading in full, and which appears to represent the most reputable, thorough, and mainstream analysis of today’s science. In it, he documents a situation that most American families are aware of — an explosion in ADHD diagnoses, which last year spiked to 11.5% (or 7 million kids), up from about 3% (or 2 million kids) in 1993.
Of those diagnosed, a disproportionate share are boys: 21% of 14-year-old boys and 23 percent of 17-year-old boys officially have ADHD, according to 2024 figures. The actual number displaying the collection of symptoms associated with ADHD is probably much higher, given that not all families pursue a formal diagnosis. Tough does not provide hard numbers on what percentage of those diagnosed are taking prescription stimulants such as Ritalin or Adderall, but says that it’s the “preferred” treatment.
Most Americans aren’t aware, however, of the sketchiness of the underlying science — which has always seemed pretty obvious to dissenters, but has now been conclusively demonstrated. The field started, Tough says, with an observation, made by a Harvard-trained psychiatrist in 1937, and since very widely replicated, that giving amphetamines to children classified as having behavioral problems has the “spectacular” effect of getting them to sit down and stay cheerfully focused on a task. Skeptics have pointed out that stimulants do that to everyone, and are popular precisely with people who wish to get through boring tasks more pleasantly (long-distance truckers, Fifties housewives, every college student unprepared for an exam).
Nonetheless, the ideas that the source of the children’s noncompliant behavior might be a physical deficit, and that the drug might correct it, has been compelling. Since the Nineties, massive amounts of research has gone into proving this attractive proposition by looking for a biomarker for ADHD (such as a gene or a correlation such as “less brain electrical activity”) and scientifically demonstrating the benefits of the treatment.
Initial results were promising, Tough writes. The Multimodal Treatment of Attention Deficit Hyperactivity Disorder Study, launched in the early Nineties and funded by National Institute of Mental Health, was “one of the largest studies ever undertaken of the long-term effects of any psychiatric medication.” In 1999, the researchers announced early results that Ritalin, their stimulant of choice, produced “significantly fewer symptoms” in children with ADHD after 14 months, compared to comparison groups of ADHD kids receiving only behavioral training or no interventions at all.
In 2017, in an effort to find a biomarker, an analysis of brain scans performed by the Enigma Consortium, a global network of scientists, announced that “patients with ADHD have altered brains; therefore ADHD is a disorder of the brain.” This was the “most ambitious” project to date, per Tough. However, his more recent conversations with the scientists who participated in those projects reveal a different story.
The brain-scan differences, he says, were either nonexistent among adults or “so minor as to be almost imperceptible” among children. Martine Hoogman, a Dutch neuroscientist who led the Enigma team, wrote to Tough in an email: “‘Back then, we emphasized the differences that we found (although small), but you can also conclude that the subcortical and cortical volumes of people with ADHD and those without ADHD are almost identical.…’ In retrospect, she added, it wasn’t fitting to conclude from her findings that A.D.H.D. is a brain disorder.”
As time passed, the MTA began to turn up different results. By 36 months on stimulants, improvements in children’s behavior had disappeared — in fact, children in all three groups demonstrated “exactly the same” level of symptoms. Moreover, careful observation of the children in question revealed a diagnosis in flux. As later studies have shown, sometimes they seemed to have ADHD, sometimes they didn’t. Sometimes children in a comparison group — who didn’t have it at the study’s outset — developed it. Tough quotes Edmund Sonuga-Barke, a researcher in psychiatry and neuroscience at King’s College London, as saying that “the traditional notion that there is a natural category of ‘people with ADHD’ that clinicians can objectively measure and define ‘just doesn’t seem to be the case.’”
“Why is the overall consensus, as Tough represents it, still so gentle in taking on the status quo?”
At the same time, situational explanations for the behaviors have seemed to grow in significance. A 2016 study published by researcher Arielle Lasky and members of the MTA group, Tough writes, interviewed adults in their mid-20s who had participated in the study as children. “Subject after subject spontaneously brought up the importance of finding their ‘niche,’ or the right ‘fit,’ in school or in the workplace,” he says. When the subjects found pursuits that were more interesting to them than school had been, their symptoms disappeared. Given such results and the difficulties of finding a biological cause, Sonuga-Barke proposes that we view ADHD not as a medical problem, but one of “misalignment” between what he tactfully calls “a child’s biological makeup” — but could also easily be called a child’s personality and situation in life — and “the environment in which they are trying to function.”
More disturbing information has come out as well. The MTA study found that after 36 months, children in the group taking Ritalin were on average one inch shorter than children in the control groups, and that the height lost was not made up later — they were still shorter as adults. And last year, a study published in The American Journal of Psychiatry found that even a medium-strength daily dose of Adderall more than tripled a patient’s likelihood of developing psychosis or mania.
Several studies have also debunked the appealing assumption that better classroom behavior actually translates to better learning. Children work faster and behave better, but Tough’s conclusions are mostly reflected by the words of F. Xavier Castellanos, a neuroscience researcher at New York University, whom he quotes: “There’s a real disconnect between the almost awesome effects on behavior and the minimal effects on academic achievement or attainment.” A 2023 study on adults found subjects’ strategies for problem-solving became “significantly worse under the medication.” It shouldn’t take a neuroscientist: Most people with any experience with recreational drugs in this category have noticed the same effect.
So why is the overall consensus, as Tough represents it, still so gentle in taking on the status quo? Why do the researchers still believe or agree that the medications are beneficial? And why does someone as smart as Tough introduce paragraphs with careful sentences such as “the failure to find a clear biomarker doesn’t mean that there is no biological basis for ADHD”?
In most human affairs, the burden of proof is on those arguing for something; we aren’t required to prove a negative to move on from a bad idea. Sonuga-Barke theorizes that research priorities have been distorted by the urgency of the children’s distress and the families needs for a solution. “In the field, we’re so frightened that people will say it doesn’t exist,” he told Tough, referring specifically to the quest for the biomarker. “We have to double down because we’re terrified of what will happen to the kids who can’t get the meds. We’ve seen the impact they can have on people’s lives.”
There is, however, urgency to a change of direction. For one thing, doctors who “believe” that stimulant medications are “on the whole, a positive thing” are unlikely to arm families with the information they need to make fully informed choices about their child’s health. The obfuscating language in Tough’s story surely is being replicated throughout the medical establishment. As James Swanson, a research psychologist who worked on the initial MTA study, told Tough, “If you’re honest, you should tell kids that, look, if you’re interested in next week or next month or even the next year, this is the right treatment for you. But in the long run, you’re going to be shorter. How many kids would agree to take medication? Probably none.”
And for another, the situation looks very different when you admit that the problem is not a physical deficit of some kind, but something afflicting a large share of children and, by my guess, most teenage boys. Diagnosing and possibly medicating these kids may get them through a bad time more successfully — it’s clearly a lifeline for many struggling families — but it does nothing to prevent the problem from arising, or to help the kids learn.
In his book The Quick Fix: Why Fad Psychology Can’t Cure Our Social Ills, which analyzes debunked science crazes in illuminating detail, the journalist Jesse Singal discovered that “at root, when society accepts a false story, it’s often because that story tells society something it wants to hear.” He also observes that it’s a pattern for junk science to be taken up when it provides “an easy way out” of a complicated problem.
In this light, we might conclude that ADHD has been an easy way to address (or not address) the vastly complicated problem that contemporary school is unsuited to the needs of a large percentage of the child population, especially boys, and desperately needs reform. We might target our attention on the long, physically confining days; the constant usage of attention-shattering screens; the stultifying conformity; the chaos-promoting soft-discipline; and the deeper questions, exacerbated by AI, of what any of it is doing and what it’s for.
Or we might target other things. But to target anything, we have to move the blame off the kids, where it never should have been in the first place. Our children’s bodies and personalities are not deficient. We are.
