Hosts
Derek Thompson
Derek ThompsonAbout the episode
In 1937, a Rhode Island psychiatrist named Charles Bradley ran an experiment on 30 child patients who had complained of headaches. He gave them an amphetamine, that is, a stimulant, called Benzedrine, which was popular at the time among jazz musicians and college students. The experiment failed, in one sense. The headaches persisted. But he noted that half of the children responded in what he called spectacular fashion, as teachers said these children seemed instantly transformed by the drug. Rather than being bored by their homework, they were interested in it. Rather than being hyperactive, they became more “placid and easygoing.” Rather than complaining to parents about chores, they would make comments like: “I start to make my bed, and before I know it, it is done.” Bradley published the results in The American Journal of Insanity, and it marks perhaps the origins of our treatment model for ADHD.
Attention-deficit/hyperactivity disorder, or ADHD, has always been hard to define. It’s harder still in an age when everybody feels like modern entertainment and the omnipresence of our screens make it hard for anybody to concentrate and sit still. But clearly, some people struggle with concentration and stillness more than others. ADHD has many classic symptoms, but it is typically marked by patterns of inattentiveness—frequently losing items, failing to follow multistep instructions—or by hyperactivity: say, fidgeting, or, for some children, being literally incapable of sitting in one place for more than half a second. In a way, I’ve always disliked the phrase “attention-deficit disorder,” because ADHD is not about a deficit of ordinary attention but a surplus of feral attention—an overflowing of raw, uncontrollable noticing.
Last week, the journalist Paul Tough published a long, 9,000-word essay in The New York Times Magazine about ADHD called “Have We Been Thinking About ADHD All Wrong?” Tough asked hard questions about why diagnoses are soaring. Is this evidence of an epidemic? Or is it evidence of overdiagnosis? Paul is today’s guest. We talk about his blockbuster essay, what its loudest critics said about it, what its loudest advocates said about it, and why they both might be wrong.
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Summary
In the following excerpt, Derek talks with Paul Tough about the changing conceptions of ADHD.
Derek Thompson: So the article is “Have We Been Thinking About ADHD All Wrong?” Let’s start big. Why did you write this, and what’s the thesis?
Paul Tough: Well, I wrote it because a few years ago I noticed that everyone around me, including me and my family, my boys, we were all struggling with attention to some degree. And so I’ve got two boys, one 10 and one 15. And so in the families that I was talking to, other parents, ADHD just kept coming up. We were talking about technology, we were talking about the pandemic, but a lot of it was talking about this particular diagnosis. Your kid’s just been diagnosed; we’re thinking about getting a diagnosis. You took the medication, and you love it. You took the medication, and you don’t love it. It was just in the air, and I felt like I didn’t understand why it was suddenly everywhere, and I didn’t understand what science was behind it. So that’s what I set out to do: to talk to the scientists who are actually investigating this condition and have been for the last few decades, in some cases, and to understand how they were thinking about ADHD.
Thompson: And what would you say is the biggest takeaway? We’re going to have a lot of time to dig into the nitty-gritty, but this is an 8,000-, 9,000- word piece. You talk to doctors, you talk to advocates of stimulants, you talk to skeptics. It’s really, really wide-ranging. I’m curious what you consider the signature overall takeaway of this essay to be.
Tough: Well, I think it’s a slightly esoteric one. So the headline is “Have We Been Thinking About ADHD All Wrong?” And so sometimes that is an opportunity to say, “We’re doing something wrong. We’re overdiagnosing, we’re overprescribing, etc.” And I think those are useful conversations to be a part of.
But part of what I’m trying to get at in this article is that literally the way we think about it and the way we talk about it within our family, to a doctor, to friends, that that actually matters. That when kids are struggling or when adults are struggling with attention or impulse control, how we talk about what’s going on in our brains and in our children’s brains, it actually matters. And the way that in our culture, and I think in a lot of the medical culture, that we talk about ADHD, there are researchers who are now saying that that model, that sort of conceptual model, is itself hurting kids and hurting families.
Thompson: I have all these questions about ADHD and the pills we prescribe and the effect that these pills have on our bodies, but there’s a way in which what you just said is almost more interesting than the next questions that I have set up for you. So I want to respond to it directly.
I am personally obsessed with this idea that the language that we use to describe our inner lives shapes our inner lives. To have a word or a term like “generalized anxiety disorder” or “ADHD” structures the way that people experience something like anxiety or an inability to pay attention. And sometimes I think that our words help us. They help us to clarify what we’ve been experiencing that we couldn’t previously clarify and thus give us not only a road map, both clinically and pharmacologically, to fix those problems but also provide us a sense of what our problems actually are. And then sometimes the words that we use can trap us. How do you think the concept of ADHD either illuminates or mystifies our experience of attention and attention disorder?
Tough: Great question. That’s what I spend a lot of time thinking about, and it’s hard to put into words. It’s hard to write about, so I’m really glad to be able to talk about it.
So yeah, I’m going to talk about two thinkers who influenced me in this, one who doesn’t write about ADHD, Rachel Aviv, a New Yorker writer and author who wrote a great book a couple of years ago called Strangers to Ourselves about mental disorders of all kinds. And her thesis as I understand it is exactly what you’re saying, that the way that we talk to people experiencing psychological distress about their distress matters a lot. So if a kid stops eating, if a girl stops eating and we say, “Oh, what’s going on? How are you feeling?” maybe we get one set of answers. And if we say, “You have anorexia, you are an anorexic, there are all these other anorexics,” that creates a different model in her mind, and it often affects the course of her illness or of her distress. And so that’s one thinker who I was really influenced by because I think something similar is going on with ADHD.
And the person who helped put that into words for me is this British psychiatrist named Edmund Sonuga-Barke, who has been studying ADHD sort of as a frontline researcher for 35 years and in the last few years has really changed his thinking about what the goal is for studying and treating ADHD. And he has turned away from what he calls the medical model of ADHD, where ADHD is a deficit in the brain. It’s a disorder. It’s neurobiological, neurodevelopmental, it’s based in genes. It is just a physical thing that is happening in certain kids’ brains and not in other kids’ brains.
And instead, he is saying, “Actually, when you look at ADHD symptoms, they are on a continuum. We’re all on this continuum somewhere.” There’s certainly people, kids, who are having a much worse time with these symptoms than others, and we need to take seriously their distress. But just telling them “You’ve got ADHD” and “You don’t have ADHD” is not always particularly helpful, and it tends to be limiting rather than liberating; it tends to tell them there’s something wrong with you. There’s something wrong with you that really can’t be fixed. It’s just deep within you, and the best that we can do is just give you this medication that is going to somehow fix it or somehow deal with this problem.
Instead, he’s saying that ADHD is better thought of as a mismatch, as a disconnect between the way your particular brain works and the circumstances that you’re in, the environment that you’re in, and that our goal is to try to solve that mismatch.
So medication can be useful. If your environment is a third grade classroom and you are having a real hard time sitting still and functioning and controlling your impulses and getting your homework done in that third grade classroom, sometimes stimulant medication is exactly the thing that is going to make that environment more tolerable.
But in other situations, maybe changing the environment can work better, changing home life, changing school life. For older kids and for adults, changing work life. When you make those changes, things change in your symptoms as well. And that’s not only more effective, it’s not only going to help more people, but it also changes the way that kids and families think about it. So rather than thinking there’s something sort of inescapably wrong with my brain, instead they can think, “This is not a great time for me and the experience I’m having, but things might change in the future.”
This excerpt has been edited and condensed.
Host: Derek Thompson
Guest: Paul Tough
Producer: Devon Baroldi