ADHD Diagnoses Have Been Rising Steadily. Why?

ADHD diagnoses are soaring. For some kids, it's a lifesaver. But recent research about ADHD shows that it might be more of a mismatch between your brain and your current circumstance -- and that labeling kids with ADHD has some downsides. In his recent article for the New York Times Magazine, Paul Tough asks "Have We Been Thinking About ADHD All Wrong?" He discusses his reporting, and listeners call in to share their experiences with ADHD diagnoses.

Alison Stewart: This is All Of It. I'm Alison Stewart, live from the WNYC studios in Soho. Thank you for spending part of your day with us. I'm grateful that you're here. On today's show, we'll continue our conversations about unputdownable novels with author Clarence Haynes. He'll be here to talk about his novel, The Ghosts of Gwendolyn Montgomery. Elyce Arons will join us to talk about her new memoir, We Might Just Make It After All: My Best Friendship with Kate Spade. New York Times cooking editor Margaux Laskey joins us with her list of easy summer meals that do not require a lot of kitchen time. That's the plan. Let's get this started with journalist Paul Tough.

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Alison Stewart: Last year, the CDC reported that a record number of American kids had been diagnosed with ADHD, attention deficit hyperactivity disorder. That number is 11.4% of children. Over the decades, as the number of diagnoses continued to rise, the medical treatment options have remained basically the same; central nervous stimulants like Ritalin and Adderall.

A recent piece in The New York Times Magazine calls our previous knowledge into question. It's titled Have We Been Thinking About ADHD All Wrong? It's about 9,000 words long. It takes about an hour to read. The author is Paul Tough, who has been covering education and child development for decades, and he joins me now to discuss. Hi, Paul.

Paul Tough: Hi.

Alison Stewart: Listeners, we want to hear from your experience. Were you diagnosed with ADHD as a kid? What was your experience like in the classroom? Did you take medication? Why or why not? Maybe you're a parent with a child of ADHD. What has the diagnosis and the treatment experience been like for you? Give us a call, 212-433-9692, 212-433-WNYC. You can call in and join us on air, or you can send a text to that number as well.

Paul, you have kids of your own. Did you know any children with ADHD?

Paul Tough: I did, yes. I have two boys who are now 10 and 15. As they grew up, I found myself often in conversations with parents from school or in the playground, where attention just kept coming up as the conversation. A lot of kids seem to be struggling with it. That was more true during the pandemic. For a lot of them, that ended up with an ADHD diagnosis.

Alison Stewart: When you say attention, how is attention defined?

Paul Tough: It's a great question because I think it's difficult to define. There are ways in which ADHD, despite the fact that the A stands for attention, doesn't necessarily have to do just with attention. There are a series of symptoms that clinicians can use to diagnose ADHD. Some of them have to do with hyperactivity and impulsivity, finding it hard to sit still, to pay attention, to take turns. Some have to do with inattention. When your mind is wandering, when you're looking out the window, when you don't hear something that someone's saying to you. All of those are kind of connected to attention, but there's a lot else going on as well.

Alison Stewart: Yes, I was curious. When parents talk to you, it's like, "Oh, Mike, he doesn't pay attention in social studies class." Was that the kind of discussion you were having with fellow parents?

Paul Tough: Well, often I think it was just-- especially during the pandemic, it was just a sense that things were out of whack. It wasn't necessarily that attention was the way that they would define it. Kids were distracted, often spending lots of time on screens, often having temper tantrums, or being unhappy. I think ADHD, in some ways, especially during those years, came to be the way that a lot of parents were encouraged to think about the distress that their kids were in.

I think every kid has trouble paying attention at certain points. Every adult does as well. I think that's more true in a technological age, more true during the pandemic. I think what this diagnosis does is gives that kind of language to a whole series of symptoms, a whole series of conditions that kids often have, and puts it in a certain lens that can be treated.

Alison Stewart: When you're writing about this, the pandemic played a significant part in this.

Paul Tough: It did. It's a little bit hard using the tools that the CDC has to track how the pandemic changed ADHD diagnoses. They went up from 6 million in 2016 to 7 million in the most recent count, which was during the pandemic. Certainly, there was an increase.

One of the things that's striking to me about the numbers of kids with ADHD is that they've continued on a pretty steady trajectory. They've been rising since the 1990s. In the 1990s, there were stories about how many kids were being prescribed Ritalin and diagnosed with ADD, as it was called at the time, but those numbers just have continued to rise pretty consistently. There might have been a spike during the pandemic, but it wasn't by any means a new story during the pandemic.

Alison Stewart: You write a lot about children. Two great books you've written: The Inequality Machine and How Children Succeed. How did you approach this story?

Paul Tough: Well, I started talking to scientists. I wanted to understand what the underlying science said about ADHD. There is a whole international community of scientists who have been studying ADHD, often since the 1990s, sometimes in long, randomized, controlled studies, sometimes working directly with kids. I wanted to understand what they knew about ADHD, how that knowledge was changing, and how it compared and connected with what families were hearing from doctors and in clinics.

Alison Stewart: What were you hearing from families?

Paul Tough: A lot of these scientists were saying that they were actually feeling less sure about the science of ADHD than they had been 10 or 20 years earlier. That around the turn of the century, there was this sense that science was on the verge of these discoveries that was going to clarify the boundaries of ADHD, which had always been a little bit hard to pin down.

In fact, a lot of what seemed like really promising scientific analyses that were going on back then mostly have not panned out over the last 20 years. What I heard from these scientists is that, in some ways, we understand less about ADHD than we thought we did 20 years ago, and our attempt to define it as a clear medical condition with very clear boundaries, we're further away from that than ever.

Alison Stewart: Currently, how is ADHD diagnosed?

Paul Tough: It's diagnosed using the DSM, the Diagnostic and Statistical Manual. What clinicians are given in the DSM is a list of symptoms. There are 18 symptoms of ADHD; 9 in this hyperlink active and impulsive category, 9 in this inattentive category. They're all behavioral in some way. Other things that you can observe in children, like I mentioned, can't sit still, can't interrupt in class, can't take turns, daydreaming, staring out the window. There's a very precise number. If a child hits six of those symptoms from either one of those categories of a certain level of impairment over a certain period of time, then they can get the diagnosis for ADHD.

This is true of lots of psychiatric disorders. The mind is a complicated thing, and clinicians need to have some kind of guidelines in order to choose who gets the diagnosis and who doesn't. The problem, I think, is that all of those numbers make it seem like there is this really clear distinction. Whereas, actually, like someone who has six of these symptoms versus someone who has five, they might not actually be all that different. I think it can be a real challenge for clinicians to know whether someone falls on one side or the other of the ADHD line.

Alison Stewart: My guest is Paul Tough, contributing writer for The New York Times Magazine. We're discussing his piece, Have We Been Thinking about ADHD All Wrong? Let's take a couple of calls. Let's talk to Lisa from the Bronx. Hi, Lisa. Thank you for making the time to call All Of It.

Lisa: Hi, thank you for taking my call. This issue is very personal to me. I am the mother of a seven-year-old girl who is brilliant and energetic, but she was diagnosed with ADHD at about, I'd say six years old. I struggled to make the decision whether I should put her on the ADHD medication or not. I literally had one half of my family saying, "Yes, put her on the medication," and the other half saying no.

I finally made the decision earlier this year because she was falling behind economically, and she's so smart. I did not want that for her. I didn't tell her teachers that she was on the medication. I waited until a parent-teacher conference just to get a gauge on how she was doing. Then I told the teacher, and the teacher said, "Oh my gosh, I noticed the difference. She's not really daydreaming as much. We don't have to redirect her attention as much."

As for my child, I've seen a difference in her attention and her behavior in school. The caveat to that is that that medication lasts from the time I give it to her right before school starts until maybe a little bit before she gets home from after school. Then I get all the behaviors that she's not exhibiting in school.

Alison Stewart: Lisa, thank you so much for calling in and sharing and being so candid. Paul, does this jive with what you found in your reporting?

Paul Tough: It does. I appreciate Lisa sharing that story as well. I think what she found is not at all uncommon. I think that there are a lot of kids who, when they're prescribed stimulant medication, especially at first, that it can really have a really rapid change on their behavior. For both hyperactive kids and inattentive kids, it can make school make sense in a way that is sometimes hard for them.

One of the things that these medications seem to do is it makes things that otherwise can seem kind of boring, it makes them interesting. It actually changes your emotional connection with the work you're supposed to be doing. Stuff that just might not seem worthwhile to a kid who is daydreaming or mind wandering, suddenly what's happening in school seems interesting enough to keep paying attention.

I think that there are a lot of kids for whom these diagnoses and these prescriptions are really positive. There are others who have less positive experiences, and there are certainly others for whom it works for a while, and then they find that the medications are less effective or that the side effects or the drawbacks outweigh the positive benefits.

What I think the approach the families take that makes the most sense to me is to not get too attached to the diagnosis or to the medication, and just wait and see how it goes. Because a lot of kids might experience symptoms at the age of Lisa's daughter, at six or seven, and then whether they're medicated or not, as they go through childhood and adolescence, those symptoms might fade, maybe for a while, maybe they come back at a certain point, depending on what else is going on in their lives, how they're feeling about school.

I think it's important for families and for kids to know that a diagnosis and a prescription, a treatment like Lisa's daughter is doing, is not necessarily a lifetime condition or a lifetime treatment. If it's working for now, great. If it stops working or stops feeling like the right approach, it's okay to try something else.

Alison Stewart: Let's talk to Joe, who is calling in from Brooklyn. Hi, Joe. Thank you for making the time to talk to us on All Of It.

Joe: Hey, Alison, thank you so much for having me.

Alison Stewart: Sure.

Joe: I've been actually prescribed ADHD medicine since about the age of five. I found it extremely helpful in my younger years. It helped me focus in school and even through college. It helped me finish college in a timely manner. The issue is, I'm now in my early 30s, and I've tried to go off the medication time and time again, and I find it extremely difficult to get off of the medication. Things that I usually find interesting on the medication, I no longer find interesting. I find motivation hard to find. That is one caveat that I will say is, try your best not to build a dependency on it.

Alison Stewart: Joe, thank you for your candor. We appreciate that. Did you hear that in your reporting, Paul?

Paul Tough: I did, yes. That's really interesting. There are lots of people who have been on different psychiatric medications for a long time who feel that when they want to stop, it's difficult. I think Joe's experience is absolutely true, but I think in general, getting off ADHD medications is easier than a lot of people feel with antidepressants or some other psychiatric medications.

In general, especially during childhood, the chemicals leave your bloodstream relatively quickly. If you don't take it for a weekend, you feel differently almost right away. It's like Lisa was describing with her daughter, that when she gets home from school, the medication is worn off. I think what Joe is describing is maybe as much a psychological conditioning or dependency as much as a physical one, that even if medically, these chemicals aren't staying in your blood for a long time, you just get used to them. You get used to that level of engagement that stimulant medication can give you, and finding ways to connect with your work or connect with what you're doing on your own, maybe you've lost that tendency that you might have gained in adolescence.

I think it's still worth trying. I think there are ways that we can retrain ourselves to focus the mind and to get interested in things. I definitely hear what Joe was saying, that it's much more difficult having taken the medication for so long.

Alison Stewart: Paul, here's an interesting text. It says, "My partner is in his mid-30s and was diagnosed with severe ADHD as a child. I've encouraged him to seek therapy to learn communication skills with his diagnosis. How much is ADHD to blame for poor social skills, and how can it change?"

Paul Tough: It's a great question. I think it's really different in everyone's case. Poor social skills is not a symptom of ADHD, but I think there are lots of people who have overlaps between ADHD and other psychological conditions. Poor social skills is not necessarily a psychological diagnosis. One of the things that was really striking to me in the data is that three-quarters of children who are diagnosed with ADHD in childhood have another diagnosis of another mental illness or mental disorder or mental condition, including anxiety, depression, autism spectrum disorder, oppositional defiant disorder.

It's another thing that I think makes the diagnosis such a challenge for a lot of clinicians to accurately do, because a lot of these kids have other conditions that are going on and to try to say, "Well, this is the one condition that we're going to put at the top of the list and that we're going to treat" can be really difficult. Maybe what this listener is describing is something that has nothing to do with their ADHD. Maybe the treatment has made it difficult for them to focus on that and learn how to deal with it.

I think the conversation that the two of them are having about how to use therapy or just conversation to work on things in yourself, I think that's always a valid and useful thing to do. The thing I worry about with some people is that ADHD can become such a compelling diagnosis that we ignore other things in our lives and think like we've got this solved because we've got the diagnosis and the prescription. As your listener is saying, actually, there are often lots of other things going on in people's lives that are worth paying attention to as well.

Alison Stewart: My guest, Paul Tough, contributing writer for The New York Times Magazine. We're discussing his piece, Have We Been Thinking About ADHD All Wrong? We'll have more after a quick break. This is All Of It.

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Alison Stewart: You are listening to All Of It on WNYC. I'm Alison Stewart. My guest is Paul Tough. He's a contributing writer for The New York Times Magazine, and we're discussing his piece, Have We Been Thinking About ADHD All Wrong? Paul, there have been efforts over the years to find a biomarker for ADHD, something that could say definitively if someone has it or doesn't have it. What have been the outcomes of those efforts?

Paul Tough: Well, the outcomes is that we do not have a biomarker for ADHD, and there are an increasing number of scientists who think that we never will. In some ways, that doesn't matter much because there is no biomarker for depression, there is no biomarker for anxiety. A lot of psychiatric disorders don't have a particular biological marker. What I think is so interesting in the ADHD story is how important it was 10 and 20 years ago to a lot of researchers to try to find one. It was this real quest in the field. I think that is partly because the boundaries of ADHD are often so difficult to define.

I think there are a lot of people who are skeptical about the ADHD diagnosis altogether, who think it's not a real disorder that doesn't exist. That is really frustrating for people like the callers that we've talked to, who are dealing with this as a condition in their lives every day. I think there was this push to try to find some biological signature that would be true of everybody with ADHD. In one experiment after another, those attempts just came up empty. Because I think the reality is that ADHD is not a black and white diagnosis, where you can easily say this person has it and this person doesn't, that a lot of these symptoms exist on a continuum that we're all on. We all struggle with these things at various times.

Inevitably, when that's the case, you're not going to have a clear biomarker that says this person has it and this person doesn't. That doesn't in any way mean that ADHD isn't a valid condition, but it does mean that the way that I think the scientists have been thinking about it as something that you can clearly, medically, scientifically say this person has it and this person doesn't, that's not the right way to think about ADHD.

Alison Stewart: In reading your piece, I had the question, why are we still treating ADHD with medication when there were questions about its long-term viability?

Paul Tough: I think that's a question a lot of people are asking. Some of the research suggests that the medications work well at the beginning, but their effectiveness fades over time. I think what your caller Lisa was saying, that in her daughter, it really did make a difference in the first-- She's only been taking it, I think she said, less than a year. It's made a real difference. She can see the difference. Her teacher can see the difference.

There are lots of kids who are helped by these medications. I think that's valid and important, and it should still be a part of the toolbox that clinicians use. I think the problem is, as your other caller, Joe, was saying, when kids are encouraged to stay on these medications as a chronic treatment, a lifelong treatment, not only do they seem to become less effective, the risk of side effects, I think, increases. Also, what Joe's describing, that it becomes difficult to make the transition from medication to a life without medication.

I think it's difficult for a lot of us to hold both of those ideas in our minds at the same time, that these can be an effective short-term treatment and for some people, a long-term treatment as well. Being on it doesn't mean you've got to stay on it forever.

Alison Stewart: Let's take a few more calls. This is Veronica, who is calling in from Brooklyn. Hi, Veronica. Thank you so much for calling All Of It.

Veronica: Hi, thank you, and thank you for having this conversation. I wanted to highlight just two quick points. Your speaker is right. There's no silver bullet when it comes to this. My son has ADHD, and he was diagnosed in second grade. He's going into sixth now. One of the things that we did is ultimately decided to give him medication. In doing that, we also spoke really openly with him early on about his learning style and with the goal of teaching him to be his best advocate in school and eventually in the future.

He articulated really well how his brain feels with ADHD. He said, in second grade, it felt like his brain was spaghetti. Over time, what we've learned with him is that he really clearly tells us when he thinks he needs medication and when he doesn't. It's the summer, he's outside playing all day for eight hours. He doesn't use medication. In school, when it's focus time, he believes that he needs it, and he makes sure that we give him his medication. That's one point.

My second point is that the NYC DOE, in our experience, is woefully unresourced and not ready to teach these kids. He went to a "good school district," but we had to fight for his support. We had to become our own advocates and become really well educated. As a result, we are leaving Brooklyn because of the challenging years we've had in elementary school here. I just wanted to say, it's really important to make your kids their own advocates. Hopefully, one day, when medication doesn't work, he still knows what he needs to do to operate. Also, the fighting the DOE is really trying and really hard. That's it.

Alison Stewart: Veronica, we wish your family the best. Let's talk to Beth in Brooklyn. Hey, Beth. Thanks for calling All Of It.

Beth: Hi, Alison. Thanks so much for taking my call. I had called at the very beginning of the show, and now I have so much to say, so I'm going to try to stay on track. I was diagnosed with ADHD as an adult while I was working in a special ed school for kids with ADHD and learning disabilities, so it was a real mind-blowing moment to be in it and of it, and it changed my life.

Unlike what your guest said, I am attached to my label and my disability. I'm one of those two-thirds of adults that don't grow out of their ADHD. I've had it my whole life. It didn't go away, and it was really empowering to know why things were so hard for me, things that other people could do that I just had no switch to turn on and get it done. "Just focus, just do it." It's maddening to hear that when you have ADHD, which is a regulation disorder.

To be able to do something about it and be like, "Okay, when I have to turn it on, here's the way I have to do that." Much like Veronica was saying, knowing how I operate and how my brain works has really helped me set myself up for success, and it's changed my self-esteem, my personal relationships, my professional life. I can't say enough about how just empowering it has been for me. I've seen that in my students as well.

Alison Stewart: Beth, thank you so much for calling in. Paul, I wanted to ask you, how can an ADHD diagnosis shape someone's identity or even shape someone's ideas about their own abilities?

Paul Tough: I think both of those calls, both what Veronica was saying about her son and what Beth was saying about her own experience, are perfect examples of the way that it can shape us. Tellingly, I think it's different. It can be different for adults and for children. I think a lot of adults, when they get the diagnosis, have exactly the experience that Beth had, that it explains a lot to them about what has happened in their life thus far. I think there are lots of people who have exactly the experience that Beth did, that that becomes very empowering, it becomes a very positive thing.

I think with kids, because their identity, their self is still in formation, that's what's going on in childhood, it's really important to do what Veronica is doing with her kid and with her son, and figure it out as you go along a little bit, like not get too attached to the diagnosis or to the medication, say it's working right now, maybe it's not working, maybe we don't need it in the summer, et cetera.

The fact that she is having those conversations with her son, encouraging him to figure out his own brain, figure out what kind of environments it works best in, when medication helps, when it doesn't, that's what everyone who is struggling with this needs so that as he gets older and moves into adolescence and adulthood, can make those decisions fully empowered. Maybe that decision will be continuing with medication. Maybe it'll change. For kids, especially, I think that openness to change, that openness to the idea that people change, is really important.

Alison Stewart: One of the things that's discussed in your piece, and people have reacted to it, is the feeling that some people with ADHD, that they think their condition is situational. One person described feeling like ADHD went away over summer vacation, and then came back when he went to school. I think we heard that from a caller as well. How does that challenge the understanding of what ADHD is and how it works?

Paul Tough: I think the reality is that lots of people have that understanding. It's exactly what Veronica was describing with her son. I do think that there is a camp within the psychiatric world that wants the definition of ADHD to be much more clear, that wants it to be a much more chronic disorder, that wants psychiatry to be the field that is able to say this person has it and this person doesn't.

I do think that it can be challenging to that idea, the experiences like Veronica's with her son, to say, "Well, it's working right now. Sometimes it doesn't work." Things change over time. One of the studies that I found most important was the study that found that among kids who are diagnosed with ADHD at about the age of Veronica's son in second and third grade, only 11% of them consistently have ADHD level symptoms throughout their childhood and adolescence. For everybody else, it comes and goes. Sometimes it goes away completely. Sometimes it goes away for a while and then comes back.

Knowing that, knowing, I think, that things change, that childhood is complicated, that adolescence is really complicated, that this condition, these symptoms can come and go, it gives you this very different sense and gives kids this very different sense of what might be ahead of them. I think when we can give that message to children that this is a serious problem at certain times in your life, it might continue to be a serious problem, it might be the thing that defines you, but it might not. It might be something that changes as you get older. I think that's really important. I think for some in the psychiatric world, that can be a challenge to the way they think about it.

Alison Stewart: Let's get one last call in here. Vincent calling in from Warren, New Jersey. Hi, Vincent. Thank you for calling All Of It.

Vimcent: Hey, good morning. Can you hear me?

Alison Stewart: You sound great. Go for it.

Vimcent: Hey. My daughter is now 23. She was diagnosed in third grade at our urging because the school system here in Jersey is very good. Once she was diagnosed, they were amazing. My point was that she was on Focalin all the way up through high school. We gave her the choice once she got into college, whether or not she needed it. I know one of your other callers had mentioned that as well, that she felt that she needed it only when she was studying or in exams in school, because she felt that the meds made her a totally different person.

It was really evident, when meds were there, it was like a light switch. Then, when the 12 hours were up, she was a totally different person. It was really kind of remarkable. I really can't urge any of these parents more than to get the help their children need because it really, really, really does make a difference in their life, because she graduated high school early, she graduated college early, all because there were so many people supporting her and the meds, obviously. Thank you for having this conversation, and just have a good day.

Alison Stewart: Thanks a lot, Vincent. Paul, before I let you go, your article has created strong reactions. Let's just say that. What do you think about that, the idea that people have such strong reactions to your piece?

Paul Tough: I think it's no surprise. The ADHD has been a controversial diagnosis, as I said, for 30 years or more. It's something that not only is the science fluid and still in formation, it's something that makes a huge difference in lots of families' lives. I think all of your callers and texters today have showed that whether treatment has been a positive thing or a negative thing for them, it is, in every case, a big deal.

If you've got a kid who is struggling with these symptoms, it can be really disruptive in a family's life. It can really hold kids back. I think the fact that people feel so connected to this question and so anxious that we're going to make the wrong decisions, I'm not surprised about that at all.

Alison Stewart: The name of the piece is Have We Been Thinking About ADHD All Wrong? Take an hour, read it all the way through. It's by Paul Tough, contributing writer to The New York Times Magazine. Thank you for sharing your reporting, Paul.

Paul Tough: Thank you so much.