Rethinking ADHD: Diagnosis, Treatment, and What Families Should Know - A Conversation with Paul Tough
In this special 200th episode, Paul Tough discusses his recent article on ADHD that has sparked significant debate. Paul explores questions like whether we're over-diagnosing ADHD, the rising diagnosis rates, and the nuances of treatment. Highlighting both the benefits and limitations of stimulant medications and the potential of environmental changes, this conversation offers valuable insights for parents and clinicians. Tune in as Paul and the host, a pediatrician, delve into the complexities of attention issues, the importance of a tailored approach, and the impact of societal and technological changes on ADHD. Don't miss this in-depth discussion that aims to provide a balanced perspective on ADHD and how families can navigate it.
00:53 Interview with Paul Tough: ADHD Insights
01:32 Understanding ADHD Diagnosis Trends
03:05 Challenges in Diagnosing ADHD
05:07 The Role of Environment in ADHD
19:13 Personal Stories and ADHD
21:58 Alternative Learning Approaches
22:24 Innovative Classroom Environments
23:18 The MTA Trial: Key Findings
25:04 Long-Term Effects of ADHD Medication
28:46 Rethinking ADHD Diagnoses
32:04 Understanding ADHD Medication
39:59 Behavioral Interventions and Environmental Changes
43:06 Final Thoughts on ADHD
Draft YouTube description
Rethinking ADHD: Diagnosis, Treatment, and What Families Should Know - A Conversation with Paul Tough
In this special 200th episode, Paul Tough discusses his recent article on ADHD that has sparked significant debate. Paul explores questions like whether we're over-diagnosing ADHD, the rising diagnosis rates, and the nuances of treatment. Highlighting both the benefits and limitations of stimulant medications and the potential of environmental changes, this conversation offers valuable insights for parents and clinicians. Tune in as Paul and th
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Episode Transcript
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Unknown (00:00):
Hello listeners. This is Dr Jessica Hochman. I'm
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(00:32):
Hi everyone, and welcome back toyour child. Is normal. I'm your
host, Dr Jessica Hochman, andtoday is a really special
milestone. This is our 200thepisode, so I just want to take
a moment to thank you, whetheryou've been listening from the
very beginning, shout out to mymom and my mother in law, or you
just found us. Thank you forbeing here, for sharing the show
with friends and for helping usto create a community that
(00:52):
celebrates the fact that so muchof what kids go through is Well,
normal. And for this bigepisode, I couldn't think of a
better guest today, I'm talkingwith Paul Tough. He's an
incredible journalist who'swriting you've probably seen in
places like the New York TimesMagazine, The Atlantic and GQ.
Paul's most recent cover storyfor The New York Times Magazine.
Have we been thinking aboutADHD? All wrong? Has sparked so
(01:14):
many important conversationsabout how we understand and
support kids with ADHD. So inour conversation, we talk about
what drew Paul to this topic,how his reporting challenged
what he thought he knew, whatthis might mean for parents,
teachers, and really, anyone whocares about kids and how they
learn and thrive. I am soexcited for you to hear this
conversation. So without furtherado, let's dive in, Paul Tough.
(01:36):
Welcome to your child as normal.
Thank you so much for beinghere. Thank you. Great to be
here. So the recent article thatyou wrote in New York Times
Magazine has gotten a lot ofattention. You asked a very
poignant question, ADHD, have webeen thinking about it wrong?
First, maybe describe what drewyou to focus on ADHD and
researching ADHD,I think I became interested in
(01:57):
it through two directions atonce, and the more immediate one
was that I'm the parent of twoboys, one is now 10 and one is
now 16, so they are in the ADHDdemographic, for sure. And a few
years ago, I just startednoticing that lots of other
parents at their schools andelsewhere were worried about
their kids' attention span andwere thinking a lot about ADHD
(02:19):
as a potential diagnosis, so Ifelt like it was in the air. And
then, more broadly, for the lastfew years, I've also just been
interested in attention as amore general question, why is it
so hard for so many of us to payattention? It certainly feels
like it's related, in some way,to the changing technologies in
our lives. But it felt likethere's something else going on
why so many kids and adults werestruggling with attention, and
(02:41):
so this ADHD felt like itintersected with both of those
questions.
I found so much of what youtalked about in your article
very interesting, especially asa pediatrician, because I am
definitely noticing more andmore families come to me
questioning whether or not theirchild has an ADHD diagnosis. And
while it's clear that thediagnosis of ADHD exists, and I
(03:05):
do see kids benefit frommedications, I do worry that
we're in an era of overdiagnosing. Is that similar to
what you found in your research?
I think it'sreally hard, certainly for me as
a journalist, to say whetherwe're over diagnosing ADHD or
not, but something is changing.
One of the things that's reallystriking about the ADHD
diagnosis rate is that it atleast among children, it hasn't
(03:28):
suddenly spiked. It has beengoing up steadily and
consistently for 30 years. Soone of the things that I did for
my reporting is looked back atthe way that ADHD and Ritalin
the main medication at the time,were being covered in the media
in the 1990s literally 30 yearsago, and it was very much the
same as it's often gets writtenabout now. Like, why is this
(03:49):
happening all of a sudden? Whysuddenly are diagnosis rates
going up so much? And when youlook at the Centers for Disease
Control Data over those 30years, it really is just this
steady increase. So it feelslike a crisis at any given time.
It feels like a sudden boom, butactually it's a very consistent
rise. So I do think there'ssomething going on, but I don't
think it's particular to thismoment.
(04:11):
So I find the actual percentagesand numbers really interesting
to hear. Can you describe to theaudience how many kids were
diagnosed with ADHD many yearsago compared to where we are
today.
So in the 90s, that first flurryof media attention came to ADHD.
It was because the total numberof young people diagnosed with
ADHD had gone up from about amillion to about 2 million. And
(04:34):
in the last few years, we'vegone up from 6 million to 7
million. So there has been thisconsistent rise, and that's 7
million children who are now,according to the CDC, have had
an ADHD diagnosis thatrepresents about 11 and a half
percent of American children,but 15% of American adolescents.
And then when you look at Boys,it's even higher. So I think
(04:55):
among 17 year old boys, it'slike 21% of them have received
and they paid. ADHD diagnosis.
So big numbers for all children,but especially large for certain
categories, especiallyadolescent boys. What
do you think is behind thisconstant surge in diagnosis? Do
you think that we're recognizingcases that weren't previously
diagnosed? Do you think it hasto do with the change in
(05:17):
society, as you mentioned, we'rein this world now that's much
more digitized, or do you thinkthere's something else going on
again? I think it's really hardto say from the numbers. My
guess, though, is that there'san all of the above quality to
it. So certainly, I think thechange in technology and with
adults, I think the change inthe way that we work has led to
problems with attention for allsorts of people, and that an
(05:40):
ADHD diagnosis can seem to a lotof adults and parents like the
right way to deal with thatincreased distractibility. I do
think there are certainadvantages that come with
getting the diagnosis, bothpractical advantages, but also,
I think sort of psychologicaladvantages. You can feel more
understood, more accepted, Ithink, when you get this
(06:02):
diagnosis. So I think that'sappealing to certain families
and certain individuals. But Ithink there's also probably some
element of social contagion. Ifyou look at the way that
different diagnoses haveincreased at different times,
especially psychological orpsychiatric diagnoses, there is
this pattern where at certainperiods, especially when news of
(06:22):
diagnoses can travel, as it doesthese days, through social
media, you can get this sort ofincrease because people just
hear about this diagnosis.
People can disagree whetherthat's because they're now
receiving this accurateinformation that helps them
understand the reality of theirlives, or whether there's
something about oursuggestibility that when we're
feeling a certain type ofdistress, when we're feeling
(06:43):
upset or distracted or havinghard time fitting into a
particular situation, if someonecomes along and says, what
you've got is x, and lots ofother people have x, and there's
this boom in x, it can be a verypowerful suggestion that is Your
situation as well. So whatpercentage of the reality of
this increase in diagnosisbelongs to each of those
(07:05):
categories? I don't think it'spossible to say, but my guess is
that there's some of all of thatgoing on.
So what I have to say definitelynotice at work is that families
or patients will come to me witha sort of self diagnosis. With
ADHD, they found a quiz online.
They take the questionnaire andthey say, oh my goodness, all of
these symptoms are nowexplained. My distractibility,
it's difficult for me toconcentrate on lectures in
(07:28):
school. And they say, This is myissue. I figured out why I've
had such trouble, and I have ahard time with this to some
degree, because while Idefinitely recognize there are
many kids that have a truedifficulty with focus. I also
think to a large degree for me,this feels very normal. I
remember being in college havinga lot of difficulty paying
attention to my history class,really struggling listening to
(07:49):
the physics lecture. So I thinkwhat I worry about is how we are
diagnosing ADHD in our currentenvironment. And my question to
you is, from your research. Doyou have any critiques or
thoughts on how we are currentlydiagnosing? ADHD,
again, I think it's really hardto say, and I'm glad that you
and other pediatricians are theones on the front lines, and not
(08:10):
me trying to figure out for anyindividual family or child what
the right approach is, becauseit's really difficult to say. So
there is this movement that I'mreally interested in in
psychiatry in general,questioning the whole notion of
diagnosis. There's a book thatjust came out, actually, since
my article came out, called theage of diagnosis, by Suzanne
(08:30):
O'Sullivan. There's another oneby a psychiatrist named Benjamin
Leahy that looks at the idea ofsort of categories of
psychiatric disorder. And bothof these researchers and lots of
others are questioning the waywe think about diagnosis, I
think that what they're sayingis that there is this human
tendency to want to say, I'vegot x, I've got y. This is, this
(08:52):
is the thing that explains mywhole life to me, and often
receiving a diagnosis like thatdoesn't turn out to be a
positive thing. It actually isdisempowering to a lot of people
to be able to categorizethemselves like that and to have
others categorize them. And sothey're suggesting that we look
at psychiatric distress inanother way, as sort of a
spectrum that everyone is on, asa collection of psychiatric
(09:16):
symptoms that often don't needto be put into certain boxes,
but still need to be takenseriously. And this is, I think,
where for you as a pediatrician,and for lots of frontline
clinicians, it gets reallycomplicated, because even though
I'm sometimes skeptical aboutindividual diagnoses of ADHD, I
am not in any way skepticalabout the underlying distress
that individuals feel. So Ithink there is real distress
(09:39):
among a lot of kids, a lot offamilies, a lot of adolescents
and a lot of young adults aswell, feeling like their minds
are not in their control, thattheir attention is not in their
control, that they are oftenreally miserable as a result.
And so I think what's tricky isto take those symptoms and take
that distress seriously and saythis is something we need to
deal with. Yeah. But to also saythat maybe an ADHD diagnosis is
(10:03):
not the best solution to thedistress that any individual is
feeling. So that's where I comedown. And I think it's a tricky
kind of conversation, as I'msure you experience every day,
to have, between a clinician anda family, and sometimes between
a clinician parents and a child,but I think it's a really
important conversation to have,and I think one risk and the
rise of ADHD diagnoses is thatit's shutting off those
(10:24):
conversations. And so when youhave this opportunity for a
family and a clinician to havethis conversation about what is
wrong in your life, what is notworking, what could we do to
change things? Instead that justgets short circuited and it is,
yep, you've got this disorder.
It's a biological disorder.
There's just something wrong inyour brain. That's all we need
to know. You're broken, andwe've got the fix, and that fix
(10:48):
is often the pharmaceutical one,and then that's the end of the
conversation. You start takingthese medications, and you don't
need any other help. You're nowon your own. And I think for
some kids and families, thatends up actually being a good
solution. But for many others,it's not. It's not the best
solution. And I think part ofwhy it's not the best solution
is that it can cut off thisopportunity for a family to
(11:11):
really have these deeperconversations about what that
child needs to be happier and tofunction better.
I have so many thoughts to whatyou just said, but first, I want
to go back really quickly. Canyou explain to everybody in your
research what is the currentgold standard for diagnosing
ADHD?
The way that clinicians aresupposed to diagnose ADHD is
(11:33):
using the Diagnostic andStatistical Manual of Mental
Disorders, the DSM. We'recurrently at the DSM five, and
that gives clinicians like you achecklist of different symptoms,
some for inattentive ADHD, somefor hyperactive or impulsive
ADHD. And there's just thischecklist. I think there are
nine potential symptoms in eachcategory, and if you have six in
(11:57):
either category, you can bediagnosed with ADHD. There are
certain other facts that need tobe met. Then you have to hit a
certain level of impairment.
They have to the symptoms haveto have existed for a certain
amount of time. They can't bebetter explained by another
psychiatric disorder. So thereis this sort of very scientific
method that you and others aresupposed to use. From my point
(12:19):
of view, it sounds really hardto do, because a lot of those
measures are very subjective.
You know, it's like the wordoften shows up a lot, like, are
you persistently impaired? Youknow, if you hit six symptoms
rather than five symptoms, youcan be diagnosed. My guess is
that for a lot of clinicians,there's a lot of subjectivity,
(12:40):
there's a lot of guesswork, andis this really the best
approach, but that is for now,at least the gold standard, the
DSM five.
What I really appreciate aboutyour research and what you've
come to find and talk about isthe nuance here. Because I do
agree that when families come totalk to me, and maybe their
child just received a diagnosisof ADHD or they're concerned,
(13:00):
that's the potential diagnosis.
I do find that some familiescome assuming that their child
will need a prescription to maketheir condition improve. But to
your earlier point, I find thatpeople are craving conversation,
that they want to know whatoptions there are. And if you
talk to them about other ways togo about it that don't involve
medication, sometimes that'smore what they are looking for.
(13:20):
And yes, I agree that for somekids, medication seems to be the
right way to go for this momentin time. But what I'm finding
really interesting is that it'sreally not what all families are
looking for.
That's really interesting. Yeah,and I'm not surprised to hear
that I think that's a realstruggle for a lot of
clinicians, is to be able totake the time to listen to what
(13:42):
patients are saying and to findthe right individual solution
for that family. And you know,there's a real attraction, I
think, both for families and forclinicians in pharmaceuticals,
in that they're a simple answer,right? They're a straightforward
answer, and the alternatives areoften kind of complicated. Like,
let's try different ways toorganize your life. Let's think
about school in a different way.
Let's think about familydynamics in a different way.
(14:05):
Like, that's hard stuff, and soI think, I think really
listening to those families andhelping them when they do want
to have that conversation iscrucial when it can happen. When
I was in my medical schooltraining, I remember there was
one psychiatrist who explainedtreating ADHD with stimulants,
as giving a child who hasdifficulty seeing and then you
(14:25):
give them their glasses. Andthis conversation came up about
when to take medications. When achild is prescribed a stimulant
medication, do you continue itthrough the weekend or just give
it to them during the schooldays? And this particular doctor
said you absolutely want toencourage parents to give a
child their medication over theweekend, because imagine not
giving someone their glassesevery day. That's unfair. A
(14:46):
child's not going to be seenclearly. They're not going to
have opportunities to learn overthe weekend. Absolutely, we
should encourage families togive their child their
medication every single day. Andwhat I've come to evolve in my
thinking as I've been practicingas a pediatrician that. That's
not the case that I really leaveit to the families. I ask the
families, what do you want? Whatdoes your child want? Do they
(15:06):
just want the medication forschool during the time when they
really need to focus? And do youwant to give them a weekend
holiday? And that's okay, and Ifind some parents like that
approach, and some parents wantit on the weekend. They need it
for their kids baseball practiceor whatnot. So what I'm trying
to say is, for myself, I foundthat with families, I approach
it in a much more individualizedmanner, that it's not a one size
(15:29):
fits all. Ithink that's great, and I think
that's hard for clinicians todo, but I think it's really
valuable when you can take thetime to have that kind of
conversation. I have also heardthat glasses analogy a lot, and
I think there's something validand valuable about it, because
it does diminish the stigma thatI think some families and some
kids can feel about takingmedication. But it also is very
(15:49):
much a biology first explanationof ADHD, right? It is expressing
ADHD as just a thing that wentwrong that happens in our eyes
and our corneas and our retinasthat like something changes in
our cones, and it it can'treally be changed back, and you
just have to deal with it. Andthen there's a way to deal with
it that's really simple andstraightforward glasses. And my
(16:11):
reading of the current researcharound ADHD is that's not
accurate in terms of ADHD, thatit's not simply a biological
disorder. I think there's stillan ongoing debate within the
scientific community, but theattempt to find a simple test,
like an eye test, that can saythis person biologically has
ADHD, has not been verysuccessful, despite a lot of
(16:34):
attempts in the past to findwhat they call a biomarker for
ADHD. And I think that one ofthe things that I think
culturally has changed over thelast few decades is that many of
us have become very attached toa biological understanding of
psychiatry. In the past, in theFreudian era, we thought this
was your psychological distress.
Was all about your relationshipwith your mother, et cetera, et
(16:57):
cetera. Now, I think we tend tolook for biological
explanations, and there'scertainly some biology at play
when it comes to ADHD, but it isnot as simple and
straightforward as what happensto your eyes when you need
glasses. And so I thinkaccepting that complication will
lead to better treatment andbetter conversations about what
ADHD is and how to treatit. So just to expand on what
(17:18):
you're saying, if I understandcorrectly, you're saying that if
we're looking for a gene or aspecific biomarker to actually
diagnose yes or no your childhas ADHD, we're likely not going
to find it. And I think thebigger picture is, does it
actually matter if a child hasthe symptoms of ADHD? Do we
actually need to find a geneticbiomarker?
(17:40):
Yeah, yeah. I think that'sexactly the question. And I
think lots of people, includingthe scientists who I
interviewed, are saying no. Thisone English or British
psychiatrist who I wrote about,Edmund sunooger bark, says this
search for a biomarker for oneparticular gene for a particular
pattern, neurological patternthat you can see on MRIs that is
associated with ADHD. It wasjust a red herring. We don't
(18:02):
need to look for that sort ofbiological marker, because what
matters is a child's distress.
And so if a child is feelingdistracted and they're upset
about it, that's real. That isour job, as the adults in their
lives, to help them deal withthat. And again, maybe
medication is the right way todo it. Maybe not, but it's a
very different situation thanthey need glasses, and so
(18:23):
they're gonna get glasses. Andso, yeah, I think sometimes the
research about biomarkers andgenes can get really
complicated, but I think what isimportant to take away from it
is that looking at ADHD assimply a biological disorder is
not not right and not the mosteffective and helpful way for
families to look at it instead,the way that a lot of the
(18:45):
researchers who I spoke tolooked at it is that it's about
a mismatch between a child'sspecific biology, their specific
brain, and their surroundings,the world they're living in,
whether that's their Family,their school, their society, the
technologies they're using,perhaps. And so how to deal with
that mismatch is a morecomplicated question. Sometimes,
(19:07):
again, medication is the bestway to do it, but sometimes
there are things that can bechanged in that child's
environment that can improve howthey're feeling, improve their
symptoms without any kind ofmedication.
I love that you describe themismatch between the brain and
the environment. I think that isabsolutely true in my
experience. I'm thinking ofexamples of my own family. My
(19:31):
sister was diagnosed with ADHD.
She struggled in school payingattention, but now she works in
sales. She does not have to sitand listen to lectures. She's
out and about meeting people,and she really thrives in that
environment. And then I thinkabout my first cousin, he also
was diagnosed with ADHD. Hecould not sit still in school.
It was really hard for him andhis family. He was put on a
stimulant medication. And nowfast forward 25 years. He's a
(19:53):
really successful fireman. Hewas just promoted to be a
captain. He thrives in thatenvironment. Environment. He
loves what he does. He is sosuccessful as a fireman, and to
me, that's a very clear exampleof a mismatch between where he
was struggling and anenvironment where he can
actually thrive. So I think it'svery true that a lot of stress
that a person with difficultywith focus and inattention may
(20:16):
have may be better served ifthey changed their environment?
Yeah, and those are fascinatingstories, and I think they really
hit home, and there's researchthat backs that up, the MTA
study, which I wrote about inthis article, a fascinating and
important study that followed agroup of children with ADHD
symptoms for more than 20 yearsinto young adulthood. It found
(20:40):
lots of important conclusionsabout ADHD and medication, but
one of the ones that I find mostinteresting was this study that
was done when the subjects werein young adulthood, like in
college and just out of college,and so many of them had found a
niche for themselves, whether itwas in school or out of school,
a new job, a major a way ofliving that was a better fit for
(21:04):
their brains, and suddenly a lotof their ADHD symptoms had gone
away, and they, in some cases,were questioning whether they
really had a disorder all along.
So I think that's really useful,and I think it is exciting when
families or when individuals canget to adulthood or adolescence
and find a niche where theyreally fit. One thing I hear
from a lot of families is thatif you're in third grade and the
(21:25):
environment where you're havingtrouble fitting in is a third
grade classroom, the option tobecome a firefighter is not
there for you right now, and soin that situation, sometimes,
yeah, the right thing to do isto look for medication or some
other more immediate treatment.
Just the fact that things aregoing to get better in the
future doesn't necessarily helpwhen you're sitting there in
that third grade classroom. ButI think it's still a really
(21:48):
useful idea for families to holdonto that this is not just
permanent biological deficit.
This is about a mismatch. Ithink that's really helpful to
know,yes, just the idea that just
because they have initiated amedication today, and then it's
useful for their child today. Itdoes not mean that they're going
to be on this medication for alifetime, by the way. Speaking
of a third grade classroomenvironment, have you ever heard
(22:09):
of give or Tully? By any chanceI haven't. No Tell me about you
might find him fascinating. Ifind him fascinating. He started
a school in San Francisco. It'sa Tinkering School, and it's
designed for kids who strugglein the classroom. And he takes
them outdoors, and he has thembuild things. And it's so
fascinating, if you look at hiswebsite, anything that they want
(22:29):
to create, he lets them createit. Oftentimes it's outdoors,
and there is even a child whomade a roller coaster. So he
lets them construct, design,create, and it's in a very
atypical classroom environment.
And while that model may be hardto scale throughout the country,
I do find it interesting thathe's thought outside the box to
(22:50):
help kids that have difficultyin school
thrive. Yeah, I think that'sreally useful. Both of my sons
have gone to tinkering classes,not as thorough going as the
school you're mentioning in SanFrancisco, but my sons love
them, and I think lots of kidsdo, and I think especially kids
for whom sitting in a desk allday, doing paperwork is not an
ideal setting, which I think ismost kids. The idea of making
(23:13):
school more active, moreengaged, more project based, I
think that's good for everybody,but I think especially for kids
who have a limited tolerance forboring stuff, I think that it's
a great solution. Now I want tobring
us back to talking about the MTAtrial, because I find the
results in this trialfascinating, and I know that in
(23:33):
over the years, this has beencited as one of the most useful,
well done ADHD trials. Can youexplain what the trial was and
what the ultimate findings were.
Yeah, so this was a study thatwas started in the early 1990s
at a moment where, as we weretalking about ADHD, diagnoses
were on the rise and Ritalin wasthe most commonly prescribed
(23:55):
medication, and there wasn't aclear answer in the field as to
whether Ritalin was actually thebest treatment for ADHD, or
whether there were behavioraltreatments or a combination that
would work best, and a group ofscientists from around North
America created this study insix sites where they recruited
young people, I think, 789, yearolds with ADHD symptoms, and
(24:18):
They divided them into differentcategories. Some would receive
medication, some would receivebehavioral treatments, some
would receive both, and somewould just be left on their own
to come up with the rightsolution for themselves. They
found two things. First of all,after 14 months, they found that
Ritalin was the most effectivetreatment for dealing with ADHD
(24:39):
symptoms. But then, after therandomized controlled trial was
over, they continued to followthese subjects in a long term
study, and they noticed that therelative effectiveness of
Ritalin was diminishing as themonths went on, and by three
years, by 36 months, there wasno difference. On average.
(25:00):
Urgent children who were in eachof these categories and so
continuing to make medication itlooked like did not actually
make a difference. They've nowcontinued to follow these kids,
as I was saying before, throughyoung adulthood, and they
continue to find that the oneswho have stayed on medication
consistently for all of thoseyears, they don't show any fewer
(25:21):
ADHD symptoms than those whonever started medication or who
started and stopped. And sothere's a lot of debate about
exactly what those results mean,but what a lot of scientists who
were involved in the studybelieve is that ADHD stimulant
treatments, Ritalin, Adderall,et cetera, they're effective in
the short term, but lesseffective in the long term. And
(25:43):
I think every individual'sresults might be different, but
I think it's a really importantidea for families to know about,
because it goes against the sortof glasses analogy, right?
Glasses continue to be usefulfor your entire life. Maybe you
need to increase yourprescription, but they remain
useful, but ADHD medications aredifferent, and that's I think,
because ADHD is different thanmyopia, and it's really useful
(26:06):
to know that fact, as you'retrying to find the right
treatment for yourself or foryour kids. I mean,
I find this really interesting,because from this MTA trial, I
believe the American Academy ofPediatrics has recommended that
the first line treatment forkids with an ADHD diagnosis,
should be starting a stimulant.
But I think it's a reallyimportant conversation piece to
bring up when we talk tofamilies about initiating
(26:27):
medication, is this very factthat, yes, we may notice a
difference initially, but overtime that effect wears off. When
I talk about this with friends,with family, they think, how can
this make sense? As you pointedout, because they seem to work
so well. But I also think thatwhen people have an ADHD
diagnosis, one explanation mayalso be that they find ways to
(26:48):
work around how they learn. Theymay learn better and catch up in
different ways. Maybe instead ofsitting down and reading, they
learn to be auditory listeners,or they find that they can learn
by moving and by walking, peoplecompensate for their
difficulties in other ways thatwe may not recognize.
Yeah, I think that's absolutelytrue, and I think the MTA study
(27:09):
is fascinating for lots ofreasons beyond that, they were
relatively effective at 14months and not relatively
effective at 36 months. One ofthe things that's fascinating
about it is that when you lookat the data, it wasn't that the
kids who had improved at 14months suddenly got a whole lot
worse at 36 months. It was thateverybody got a little bit
better. And that suggestssomething, right? It suggests
(27:30):
that ADHD symptoms, often askids get older, diminish. And
other studies that the MTAscientists have done with that
same group of subjects haveshowed that, in fact, there are
all sorts of fluctuations thathappen with symptoms over the
course of childhood. It's notthe case that everyone's just go
away, but it is the case thatthey go up and down a lot,
(27:51):
sometimes in unpredictable ways,through childhood, through
adolescence and into adulthood.
One fact that from one of thesestudies that I found really
significant is that only about11% one in nine kids who have
the symptoms at seven or eightor nine persistently hit the
clinical threshold of symptomsall the way through childhood
and adolescence. Everybody else,almost 90% their symptoms go
(28:14):
below that threshold for acertain period. Sometimes they
go away altogether, sometimesthey go away and come back and
so that doesn't just mean don'tworry about ADHD. It'll just go
away on its own, but it doesmean that again, this glasses
analogy is not a helpful one.
That doesn't happen when youneed glasses. It's not like for
a couple of years, your eyessuddenly get better. I
(28:35):
also find that a lot of parentseither they don't want their
kids on a medication or theystart their kids on a medication
they don't like the effects. Ithink that the results of this
trial give validity to the ideathat it is a choice, that you
can take a stimulant medication,but you also can approach the
diagnosis with Nuance.
Yeah, absolutely. One idea thatI have found really meaningful
(28:56):
is this idea that I think comesout of this new thinking about
diagnosis in general, that adiagnosis, I think some of us
have a tendency to want to clingreally tightly to a diagnosis,
to have it be the explanatoryforce in our whole lives, and
that I think it's much morepractically helpful and maybe
psychologically helpful to hangon to diagnoses, psychological
diagnoses lightly, right? Thisis one idea that might tell me
(29:19):
something about what is going onin my life right now, or my
child's life right now, but it'snot going to be the explanatory
force in their whole life. Maybethis is something that is true
now and won't be true in thefuture. Maybe it's going to go
away altogether. Maybe it'sgoing to get worse, but it's not
something to hang on tootightly. And when you do that, I
think it opens you up to reallyfollowing the evidence in your
(29:41):
child's life, right? Maybe thesesymptoms aren't so bad, and they
were bad a little while ago. Weshould try going off the
medication, as you were saying,like maybe you don't need this
medication on the weekend orover the summer. All of that, I
think, just not only leads tobetter practical outcomes, but
it also helps families thinkabout. This diagnosis in a much
(30:02):
healthier way, that this isn'tsomething that's like a
permanent deficit, a permanentdisorder that's wrong with your
kid. It is a situation that isserious, but that is about right
now, and if we don't hang on toit too tightly, things might
change. Things might get better.
That's a really positivemessage, I think, as well as a
very realistic one to give tokids and to give to families.
Absolutely the message that weevolve, things aren't forever,
(30:25):
things aren't permanent, Ithink, is a very helpful
message, because, to your point,earlier, labels have their use.
It can be helpful. It can makekids feel understood. It can
make parents feel like theirchild is more understood, like
they have a direction and a pathforward. But at the same time.
Sometimes I find that labels canbe limiting. I think the title
of my podcast, your child isnormal, stems from that idea
(30:47):
that sometimes these behaviorsthat we're so quick to want to
diagnose, to want to treat,oftentimes, these are just
normal childhood behaviors. Andkids aren't easy all the time.
They're difficult to raise. Theycan be feral. They can be wild,
and I think sometimes it's justnormal.
Yeah, I think that's reallytrue. And there's, I think
that's true on an anecdotallevel, like that I see in the
(31:10):
kids around me, I'm sure in themany more kids every day and
every week. But there's alsoresearch that suggests that, I
think there was this idea a fewyears ago, especially, that
giving a kid a biologicallybased diagnosis and saying
you've got this biologicaldisorder in your brain that
would diminish stigma, thatwould tell them it wasn't their
fault, it was just this thingthat was broken in their brain.
(31:31):
But there are lots of studiesthat say the opposite, and those
make a lot of sense to me, thattelling a kid there is something
broken in your brain does nothelp them feel better about
themselves and about theirpotential and their future, and
then instead telling them what Ithink is this much more
realistic story about ADHD as aproblem they've got right now
that might have to do with amismatch that is part of
(31:51):
something that we're all we allexperience to a certain degree,
some worse and more than others,and that might go away in the
future that is just gonna leadto a more psychologically
healthy outcome for them,they're not going to feel like
this is the thing that definesme, this is the thing that makes
me different from everybodyelse. They're going to think
this is a problem I've got totake seriously right now, but
(32:11):
it's not who I am.
So I want to ask you more aboutmedications and how they're
thought to work, and thepotential side effects that may
come from the medications. So myfirst question, why do we think
stimulants work in the firstplace?
They do tough? Said, so, youknow, these stimulants are all
based in amphetamines, and wehave known now for almost 100
years in this country thatamphetamines are a really
(32:33):
powerful drug, and they havegood effects, and they can have
some bad effects as well. Andthey kind of do that with
everybody. I think there's thisidea that some people in the
ADHD world believe it, thatthese medications are only
effective on people who have anADHD diagnosis. But that's not
the case. There are lots ofstudies that show anyone who
takes these medications oramphetamines in any way, they
(32:55):
have some version of the sameresponse, which is, they can
focus more. They don't careabout distractions. They have a
much higher tolerance for boringstuff. The Times, historically,
when we've used it have beenlike with people who are doing
incredibly boring jobs, soldierswho have to stay up all night
just staring at the sky,watching for planes, long haul
(33:17):
truck drivers, these are allpeople for whom amphetamines
have been really useful becausethey let you focus on things
that are kind of boring. HighSchools, for instance, is also
kind of boring, and so it makessense that these medications
would help kids focus, but therehave always been downsides to
amphetamines, and I shouldclarify that the medications
that we're giving kids now havea lot of safety features that
(33:40):
make them less prone to abusethan amphetamine medications in
the past, but it's still thesame basic drug, and it's always
had downsides. So a lot of theyoung people who I spoke to said
they felt like it changed theirpersonality, they were less
social, they were less able toengage. All of which makes
sense, right? If you're onlyfocused on the one thing in
(34:01):
front of you, you're not asfunny, you're not as fun, you're
not as spontaneous. And so Ithink a lot of families, a lot
of kids, say they don't like theeffects, and a lot of them stop
taking it over time. But in theshort term, in terms of managing
those symptoms, diminishing thatdistractibility, letting you
focus on the stuff you'resupposed to focus on, on
(34:24):
average, they're reallyeffective with lots of people,
but it does not make yousmarter, correct, it does not
change your IQ. So in essence,what you're saying is the
medications work by helping youfocus on boring tasks. They make
boring tasks less boring, andyou're able to sit and focus and
focus and do things that youmight not want to do, or a less
preferred task.
That's right. Sometimes amongcollege students, anyway, they
(34:46):
have the nickname smart pills,and they are not smart pills.
They don't make you smarter.
There are lots of studies,including some that I read
about, that show that incontrolled situations, when
scientists divide kids up intothose who receive the
medication. And those who don't,the ones who receive the
medication, do behave better.
They act out less, they focus ontheir work more. But when you
(35:07):
test them on how much they'velearned or how able they are to
answer complicated questions,there is no real difference
between the kids who receive themedication and who don't, and
we're not entirely sure why thatis, but the theory that makes a
lot of sense to me is to thinkthat we should be thinking about
these stimulant medications asworking on our emotions and our
(35:27):
motivation more than on ourcognition. It changes the way
you feel about the work thatyou're doing. And that's not
nothing. Emotion is certainlyimportant, and it's a big deal
for every kid, but it's reallyvaluable, I think, to understand
that's what's happening. Whatwe're doing is not making
ourselves smarter, not makingourselves better able to do
these tasks, it's changing theway we feel about the work we're
(35:49):
doing. Sometimes temporarily, Ifind that a lot of parents worry
that their kids are more likelyto be to be addicted to these
medications over time, that itmight be a gateway drug to more
drugs in the future. So Iappreciate that you mentioned
that these drugs are formulatedto keep kids from growing an
addiction to the stimulantmedications. But there are some
real side effects, and you touchupon a lot of them in your
(36:11):
article. Can you mention some ofthe real side effects that you
noticed that might surprisepeople listening?
Well, the side effect that theMTA study pointed out, which I
think is a surprise to a lot offamilies, is about height
suppression. And again, there'sdebate in the scientific
community about how consistentthis result is, but in the MTA
(36:31):
study, at least children whoconsistently took stimulant
medication over time were aboutan inch shorter than their peers
who didn't take thosemedications. And initially, the
researchers thought that thiswas just a short term, temporary
difference in height and that itwas going to change as kids hit
(36:52):
puberty. But it doesn't,according to the MTA, and when
they now look at the adults, theones who have consistently taken
medication are still an inchshorter than their peers. There
are lots of people who say thatis a small price to pay for the
benefits of medication, but itis absolutely something I think
that kids and families should beaware of, and I think it's
another reason to think aboutstimulant medication, not
(37:15):
necessarily as a long termsolution, but as a short term
solution, as something to tryfor a while to get through a
crisis period, but it's, onaverage, at least a significant
effect, according to the MTA oflong term stimulant use.
Yes, and to your point, I thinkthat takes me back to the idea
of making it a shared decisionthat you want parents to
understand the full potentialbenefits and the full potential
(37:37):
negatives. As you pointed out,an inch may not be much to
somebody who's struggling withbehavioral issues with their
child, and they feel like thestimulant makes a big difference
in their quality of life, in thelife of their child and the life
of their family. But for somefamilies, that's important, and
I think that's reallyinteresting to point out, I
agree. I also find too it'sstressful for families that kids
(37:58):
have a diminished appetite thatcauses a lot of stress. For a
lot of kids, when the medicationwears off, they seem more
irritable. So they may get thebenefit of a focused child for a
few hours, but then as themedication wears off, that can
also be stressful for families,some kids suffer from insomnia,
so I find that they may be on astimulant during the day, but
then they end up needing anothermedication or something else to
(38:20):
help them sleep at night. Andfor kids that have tics, once
they're started on a stimulantmedication, those tics may
exacerbate so there are a lot ofside effects to these
medications that I think it'sworth bringing to light, just so
that parents can take all thesefactors into consideration.
Yeah, I think it's a seriousmedication for sure, and it
doesn't simply make it easier topay attention and not have any
(38:42):
other effects. I felt I learneda lot from talking to the young
people, mostly adolescents, whohad taken the medication. And
some of them were more positiveabout the experience than
others, but all of them saw itas a series of trade offs. The
one word a few of them used wasa sacrifice. This is not
something I like doing, but Isee it as a sacrifice that I
have to make for the future. Andthe adolescents themselves have
(39:04):
these very nuanced approaches,like I take it on certain days
when I need to feel one way orneed to do certain tasks and not
on other days. There was onegirl I spoke to who it was like
the end of summer, and she wasabout to say goodbye to her
friends who were all going backto college, and she said she
didn't take it that day so thatshe could have the more deep
sort of emotional connectionwith sadness of her friends
(39:27):
going away, because she knewthat if she was on the
medication that day, there wouldbe something diminished about
her emotional responses. So Ithink really listening to kids,
especially adolescents, as theyget more expressive about what
their experience is with thatmedication, how it makes them
feel in different situations,that's really important. And I
think there's sometimes apressure on families that the
(39:48):
only conversation should be likethe adults telling the kids to
take these medications and makesure you do it on time. And I
think when you can have a realconversation about what the
pluses and what the minuses areof taking the medication, you.
It's going to be a much moresuccessful experience. So
this is really helpful, and Iwant to talk now beyond
medications. In your article,you highlighted how changing a
(40:09):
child's environment may easesymptoms. Can you give an
example of what that might looklike? I want to make sure
families understand the otheroptions that are out there
beyond medication.
So there are lots of behavioralinterventions, some whole
programs that have particularnames and some that are just
more ad hoc. My understanding isthat there isn't one that,
(40:31):
through a rigorous test, beenproven to be more effective than
medication over the long haul.
But I don't think that meansthat environmental changes can't
be very effective. I just thinkthey have to be more
individualized and spontaneousand reflective of the individual
child. Changing the dynamic athome can often make a big
difference when kids feel moreaccepted and understood, when
(40:55):
they feel like theirdistractibility or their
problems staying focused aresomething that they can work on,
sometimes with little fixes likepost it notes and lists on the
wall and schedules and that thisis something that they can get
better at with help and witheffort. I think that's can often
lead to really positive changes.
And similarly, at school, thereare ways that assignments can be
(41:18):
more or less distracting whenchanges can happen in the way
that a classroom is set up whereyou do homework, when that can
change, sometimes in small ways,it can really help. I don't
think there's a magic bulletwhere we can say this is the
behavioral intervention that'salways work, but I do think that
changing environments can help.
Yes, Iespecially find that for the
young boy, 789, 10 years old,who's got a lot of energy and
(41:41):
can't sit still in theclassroom. I'll often advise
parents to talk to teachersabout making sure they have
their recess, making sure theymove their bodies, maybe doing
jumping jacks in the middle ofclass, taking 10 minutes before
school starts to run sprints,similar to having a puppy. You
gotta get their energy out orthey're not gonna sit still.
Totally Yeah, I think that'sabsolutely right. And I think
(42:04):
again, it comes down tocommunication and understanding
between the child, parents andideally, a teacher in a school,
and that when all of those threeindividuals are able to work
together and to see this as aproblem that is real, but that
is solvable. You can often comeup with some really creative
solutions. And I think that ideaof thinking of it as a solvable
(42:28):
problem is psychologicallyreally positive for the kids,
because they don't think, Oh,this is my problem. This is a
disorder that I've got thatmeans I'm different, that means
I'm weird, that means I'mbroken. Instead, they're like,
this is something that we cansolve and that we're all going
to solvetogether. Absolutely I do feel
like this is a group effort. Ifind a lot of parents come to me
either stressed because theyfeel like the teacher is asking
(42:49):
for the parent to come to me torequest medication, or I find
often that parents are relievedthat their teacher understands
that the child is havingdifficulty, works to make
accommodations for thatparticular child. Maybe they're
an experienced teacher, orthey've had a child themselves
that struggled, and that is sorelieving for families when they
feel like their child isunderstood for sure.
(43:14):
So as we wrap up,if you could change one thing
about the way we talk aboutADHD, what do you want parents
to better understand?
I think it's really useful forparents to understand that an
ADHD diagnosis is not a sort ofpermanent and essential thing
about a child, that it does notindicate that this child has a
(43:37):
brain defect that is permanentand is never going to change,
never going to go away. And Ithink that's important for a
couple of reasons. I think it'simportant because it's true,
because I think all the evidenceis there that we can't say that
for sure about ADHD, I thinkit's important because on a
practical level, it's going tolead to better solutions. It's
(43:57):
going to push parents, I think,to find solutions and to work
with their kids and theirpediatricians and their kids
teachers to find good solutions.
And I think it's also reallyimportant psychologically, that
it gives the message to childrenwho I think are really the ones
we need to care about the mostin this dynamic, that they are
not broken, that they don't havethis deficit that is never going
(44:20):
to go away, that they have aserious situation that they need
to take seriously with theirfamily's help and with their
school's help and with theirpediatricians help. This is not
the thing that's going to be themost important fact in their
lives. This is going to be onething that is worth dealing with
and worth thinking about, butit's not going to be the thing
that defines the rest of theirlives.
(44:40):
And if people want to read moreabout what you do, where can
they find you? Ihave a website at Paul tough.com
that has links to my stories andmy books, so that's a good place
to start.
Paul Tough, thank you so muchfor the research that you do,
and I really appreciate youtaking the time to come on your
child as normal.
Thank you so much. Thanks forinviting me on.
Thank you. So much. Thanks.
(45:01):
Thank you so much for listeningto my conversation with Paul
Tough and for joining me for thespecial 200th episode. And if
you enjoyed today's episode, itwould mean the world to me if
you could do two things, sharethis episode with a friend or
another parent who might find ithelpful, and leave a five star
review wherever it is. Youlisten to podcasts, it really
helps other parents find theshow and join this community.
(45:22):
See you next Monday. You.
Hello listeners. This is Dr Jessica Hochman. I'm
(00:02):
excited to share that I am nowbooking sponsorships for your
child as normal for this fall.
If you have a product, serviceor a message that you think our
listeners would benefit from,whether it's for parents, kids,
healthcare or family life ingeneral, this could be a great
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get back to you.
(00:32):
Hi everyone, and welcome back toyour child. Is normal. I'm your
host, Dr Jessica Hochman, andtoday is a really special
milestone. This is our 200thepisode, so I just want to take
a moment to thank you, whetheryou've been listening from the
very beginning, shout out to mymom and my mother in law, or you
just found us. Thank you forbeing here, for sharing the show
with friends and for helping usto create a community that
(00:52):
celebrates the fact that so muchof what kids go through is Well,
normal. And for this bigepisode, I couldn't think of a
better guest today, I'm talkingwith Paul Tough. He's an
incredible journalist who'swriting you've probably seen in
places like the New York TimesMagazine, The Atlantic and GQ.
Paul's most recent cover storyfor The New York Times Magazine.
Have we been thinking aboutADHD? All wrong? Has sparked so
(01:14):
many important conversationsabout how we understand and
support kids with ADHD. So inour conversation, we talk about
what drew Paul to this topic,how his reporting challenged
what he thought he knew, whatthis might mean for parents,
teachers, and really, anyone whocares about kids and how they
learn and thrive. I am soexcited for you to hear this
conversation. So without furtherado, let's dive in, Paul Tough.
(01:36):
Welcome to your child as normal.
Thank you so much for beinghere. Thank you. Great to be
here. So the recent article thatyou wrote in New York Times
Magazine has gotten a lot ofattention. You asked a very
poignant question, ADHD, have webeen thinking about it wrong?
First, maybe describe what drewyou to focus on ADHD and
researching ADHD,I think I became interested in
(01:57):
it through two directions atonce, and the more immediate one
was that I'm the parent of twoboys, one is now 10 and one is
now 16, so they are in the ADHDdemographic, for sure. And a few
years ago, I just startednoticing that lots of other
parents at their schools andelsewhere were worried about
their kids' attention span andwere thinking a lot about ADHD
(02:19):
as a potential diagnosis, so Ifelt like it was in the air. And
then, more broadly, for the lastfew years, I've also just been
interested in attention as amore general question, why is it
so hard for so many of us to payattention? It certainly feels
like it's related, in some way,to the changing technologies in
our lives. But it felt likethere's something else going on
why so many kids and adults werestruggling with attention, and
(02:41):
so this ADHD felt like itintersected with both of those
questions.
I found so much of what youtalked about in your article
very interesting, especially asa pediatrician, because I am
definitely noticing more andmore families come to me
questioning whether or not theirchild has an ADHD diagnosis. And
while it's clear that thediagnosis of ADHD exists, and I
(03:05):
do see kids benefit frommedications, I do worry that
we're in an era of overdiagnosing. Is that similar to
what you found in your research?
I think it'sreally hard, certainly for me as
a journalist, to say whetherwe're over diagnosing ADHD or
not, but something is changing.
One of the things that's reallystriking about the ADHD
diagnosis rate is that it atleast among children, it hasn't
(03:28):
suddenly spiked. It has beengoing up steadily and
consistently for 30 years. Soone of the things that I did for
my reporting is looked back atthe way that ADHD and Ritalin
the main medication at the time,were being covered in the media
in the 1990s literally 30 yearsago, and it was very much the
same as it's often gets writtenabout now. Like, why is this
(03:49):
happening all of a sudden? Whysuddenly are diagnosis rates
going up so much? And when youlook at the Centers for Disease
Control Data over those 30years, it really is just this
steady increase. So it feelslike a crisis at any given time.
It feels like a sudden boom, butactually it's a very consistent
rise. So I do think there'ssomething going on, but I don't
think it's particular to thismoment.
(04:11):
So I find the actual percentagesand numbers really interesting
to hear. Can you describe to theaudience how many kids were
diagnosed with ADHD many yearsago compared to where we are
today.
So in the 90s, that first flurryof media attention came to ADHD.
It was because the total numberof young people diagnosed with
ADHD had gone up from about amillion to about 2 million. And
(04:34):
in the last few years, we'vegone up from 6 million to 7
million. So there has been thisconsistent rise, and that's 7
million children who are now,according to the CDC, have had
an ADHD diagnosis thatrepresents about 11 and a half
percent of American children,but 15% of American adolescents.
And then when you look at Boys,it's even higher. So I think
(04:55):
among 17 year old boys, it'slike 21% of them have received
and they paid. ADHD diagnosis.
So big numbers for all children,but especially large for certain
categories, especiallyadolescent boys. What
do you think is behind thisconstant surge in diagnosis? Do
you think that we're recognizingcases that weren't previously
diagnosed? Do you think it hasto do with the change in
(05:17):
society, as you mentioned, we'rein this world now that's much
more digitized, or do you thinkthere's something else going on
again? I think it's really hardto say from the numbers. My
guess, though, is that there'san all of the above quality to
it. So certainly, I think thechange in technology and with
adults, I think the change inthe way that we work has led to
problems with attention for allsorts of people, and that an
(05:40):
ADHD diagnosis can seem to a lotof adults and parents like the
right way to deal with thatincreased distractibility. I do
think there are certainadvantages that come with
getting the diagnosis, bothpractical advantages, but also,
I think sort of psychologicaladvantages. You can feel more
understood, more accepted, Ithink, when you get this
(06:02):
diagnosis. So I think that'sappealing to certain families
and certain individuals. But Ithink there's also probably some
element of social contagion. Ifyou look at the way that
different diagnoses haveincreased at different times,
especially psychological orpsychiatric diagnoses, there is
this pattern where at certainperiods, especially when news of
(06:22):
diagnoses can travel, as it doesthese days, through social
media, you can get this sort ofincrease because people just
hear about this diagnosis.
People can disagree whetherthat's because they're now
receiving this accurateinformation that helps them
understand the reality of theirlives, or whether there's
something about oursuggestibility that when we're
feeling a certain type ofdistress, when we're feeling
(06:43):
upset or distracted or havinghard time fitting into a
particular situation, if someonecomes along and says, what
you've got is x, and lots ofother people have x, and there's
this boom in x, it can be a verypowerful suggestion that is Your
situation as well. So whatpercentage of the reality of
this increase in diagnosisbelongs to each of those
(07:05):
categories? I don't think it'spossible to say, but my guess is
that there's some of all of thatgoing on.
So what I have to say definitelynotice at work is that families
or patients will come to me witha sort of self diagnosis. With
ADHD, they found a quiz online.
They take the questionnaire andthey say, oh my goodness, all of
these symptoms are nowexplained. My distractibility,
it's difficult for me toconcentrate on lectures in
(07:28):
school. And they say, This is myissue. I figured out why I've
had such trouble, and I have ahard time with this to some
degree, because while Idefinitely recognize there are
many kids that have a truedifficulty with focus. I also
think to a large degree for me,this feels very normal. I
remember being in college havinga lot of difficulty paying
attention to my history class,really struggling listening to
(07:49):
the physics lecture. So I thinkwhat I worry about is how we are
diagnosing ADHD in our currentenvironment. And my question to
you is, from your research. Doyou have any critiques or
thoughts on how we are currentlydiagnosing? ADHD,
again, I think it's really hardto say, and I'm glad that you
and other pediatricians are theones on the front lines, and not
(08:10):
me trying to figure out for anyindividual family or child what
the right approach is, becauseit's really difficult to say. So
there is this movement that I'mreally interested in in
psychiatry in general,questioning the whole notion of
diagnosis. There's a book thatjust came out, actually, since
my article came out, called theage of diagnosis, by Suzanne
(08:30):
O'Sullivan. There's another oneby a psychiatrist named Benjamin
Leahy that looks at the idea ofsort of categories of
psychiatric disorder. And bothof these researchers and lots of
others are questioning the waywe think about diagnosis, I
think that what they're sayingis that there is this human
tendency to want to say, I'vegot x, I've got y. This is, this
(08:52):
is the thing that explains mywhole life to me, and often
receiving a diagnosis like thatdoesn't turn out to be a
positive thing. It actually isdisempowering to a lot of people
to be able to categorizethemselves like that and to have
others categorize them. And sothey're suggesting that we look
at psychiatric distress inanother way, as sort of a
spectrum that everyone is on, asa collection of psychiatric
(09:16):
symptoms that often don't needto be put into certain boxes,
but still need to be takenseriously. And this is, I think,
where for you as a pediatrician,and for lots of frontline
clinicians, it gets reallycomplicated, because even though
I'm sometimes skeptical aboutindividual diagnoses of ADHD, I
am not in any way skepticalabout the underlying distress
that individuals feel. So Ithink there is real distress
(09:39):
among a lot of kids, a lot offamilies, a lot of adolescents
and a lot of young adults aswell, feeling like their minds
are not in their control, thattheir attention is not in their
control, that they are oftenreally miserable as a result.
And so I think what's tricky isto take those symptoms and take
that distress seriously and saythis is something we need to
deal with. Yeah. But to also saythat maybe an ADHD diagnosis is
(10:03):
not the best solution to thedistress that any individual is
feeling. So that's where I comedown. And I think it's a tricky
kind of conversation, as I'msure you experience every day,
to have, between a clinician anda family, and sometimes between
a clinician parents and a child,but I think it's a really
important conversation to have,and I think one risk and the
rise of ADHD diagnoses is thatit's shutting off those
(10:24):
conversations. And so when youhave this opportunity for a
family and a clinician to havethis conversation about what is
wrong in your life, what is notworking, what could we do to
change things? Instead that justgets short circuited and it is,
yep, you've got this disorder.
It's a biological disorder.
There's just something wrong inyour brain. That's all we need
to know. You're broken, andwe've got the fix, and that fix
(10:48):
is often the pharmaceutical one,and then that's the end of the
conversation. You start takingthese medications, and you don't
need any other help. You're nowon your own. And I think for
some kids and families, thatends up actually being a good
solution. But for many others,it's not. It's not the best
solution. And I think part ofwhy it's not the best solution
is that it can cut off thisopportunity for a family to
(11:11):
really have these deeperconversations about what that
child needs to be happier and tofunction better.
I have so many thoughts to whatyou just said, but first, I want
to go back really quickly. Canyou explain to everybody in your
research what is the currentgold standard for diagnosing
ADHD?
The way that clinicians aresupposed to diagnose ADHD is
(11:33):
using the Diagnostic andStatistical Manual of Mental
Disorders, the DSM. We'recurrently at the DSM five, and
that gives clinicians like you achecklist of different symptoms,
some for inattentive ADHD, somefor hyperactive or impulsive
ADHD. And there's just thischecklist. I think there are
nine potential symptoms in eachcategory, and if you have six in
(11:57):
either category, you can bediagnosed with ADHD. There are
certain other facts that need tobe met. Then you have to hit a
certain level of impairment.
They have to the symptoms haveto have existed for a certain
amount of time. They can't bebetter explained by another
psychiatric disorder. So thereis this sort of very scientific
method that you and others aresupposed to use. From my point
(12:19):
of view, it sounds really hardto do, because a lot of those
measures are very subjective.
You know, it's like the wordoften shows up a lot, like, are
you persistently impaired? Youknow, if you hit six symptoms
rather than five symptoms, youcan be diagnosed. My guess is
that for a lot of clinicians,there's a lot of subjectivity,
(12:40):
there's a lot of guesswork, andis this really the best
approach, but that is for now,at least the gold standard, the
DSM five.
What I really appreciate aboutyour research and what you've
come to find and talk about isthe nuance here. Because I do
agree that when families come totalk to me, and maybe their
child just received a diagnosisof ADHD or they're concerned,
(13:00):
that's the potential diagnosis.
I do find that some familiescome assuming that their child
will need a prescription to maketheir condition improve. But to
your earlier point, I find thatpeople are craving conversation,
that they want to know whatoptions there are. And if you
talk to them about other ways togo about it that don't involve
medication, sometimes that'smore what they are looking for.
(13:20):
And yes, I agree that for somekids, medication seems to be the
right way to go for this momentin time. But what I'm finding
really interesting is that it'sreally not what all families are
looking for.
That's really interesting. Yeah,and I'm not surprised to hear
that I think that's a realstruggle for a lot of
clinicians, is to be able totake the time to listen to what
(13:42):
patients are saying and to findthe right individual solution
for that family. And you know,there's a real attraction, I
think, both for families and forclinicians in pharmaceuticals,
in that they're a simple answer,right? They're a straightforward
answer, and the alternatives areoften kind of complicated. Like,
let's try different ways toorganize your life. Let's think
about school in a different way.
Let's think about familydynamics in a different way.
(14:05):
Like, that's hard stuff, and soI think, I think really
listening to those families andhelping them when they do want
to have that conversation iscrucial when it can happen. When
I was in my medical schooltraining, I remember there was
one psychiatrist who explainedtreating ADHD with stimulants,
as giving a child who hasdifficulty seeing and then you
(14:25):
give them their glasses. Andthis conversation came up about
when to take medications. When achild is prescribed a stimulant
medication, do you continue itthrough the weekend or just give
it to them during the schooldays? And this particular doctor
said you absolutely want toencourage parents to give a
child their medication over theweekend, because imagine not
giving someone their glassesevery day. That's unfair. A
(14:46):
child's not going to be seenclearly. They're not going to
have opportunities to learn overthe weekend. Absolutely, we
should encourage families togive their child their
medication every single day. Andwhat I've come to evolve in my
thinking as I've been practicingas a pediatrician that. That's
not the case that I really leaveit to the families. I ask the
families, what do you want? Whatdoes your child want? Do they
(15:06):
just want the medication forschool during the time when they
really need to focus? And do youwant to give them a weekend
holiday? And that's okay, and Ifind some parents like that
approach, and some parents wantit on the weekend. They need it
for their kids baseball practiceor whatnot. So what I'm trying
to say is, for myself, I foundthat with families, I approach
it in a much more individualizedmanner, that it's not a one size
(15:29):
fits all. Ithink that's great, and I think
that's hard for clinicians todo, but I think it's really
valuable when you can take thetime to have that kind of
conversation. I have also heardthat glasses analogy a lot, and
I think there's something validand valuable about it, because
it does diminish the stigma thatI think some families and some
kids can feel about takingmedication. But it also is very
(15:49):
much a biology first explanationof ADHD, right? It is expressing
ADHD as just a thing that wentwrong that happens in our eyes
and our corneas and our retinasthat like something changes in
our cones, and it it can'treally be changed back, and you
just have to deal with it. Andthen there's a way to deal with
it that's really simple andstraightforward glasses. And my
(16:11):
reading of the current researcharound ADHD is that's not
accurate in terms of ADHD, thatit's not simply a biological
disorder. I think there's stillan ongoing debate within the
scientific community, but theattempt to find a simple test,
like an eye test, that can saythis person biologically has
ADHD, has not been verysuccessful, despite a lot of
(16:34):
attempts in the past to findwhat they call a biomarker for
ADHD. And I think that one ofthe things that I think
culturally has changed over thelast few decades is that many of
us have become very attached toa biological understanding of
psychiatry. In the past, in theFreudian era, we thought this
was your psychological distress.
Was all about your relationshipwith your mother, et cetera, et
(16:57):
cetera. Now, I think we tend tolook for biological
explanations, and there'scertainly some biology at play
when it comes to ADHD, but it isnot as simple and
straightforward as what happensto your eyes when you need
glasses. And so I thinkaccepting that complication will
lead to better treatment andbetter conversations about what
ADHD is and how to treatit. So just to expand on what
(17:18):
you're saying, if I understandcorrectly, you're saying that if
we're looking for a gene or aspecific biomarker to actually
diagnose yes or no your childhas ADHD, we're likely not going
to find it. And I think thebigger picture is, does it
actually matter if a child hasthe symptoms of ADHD? Do we
actually need to find a geneticbiomarker?
(17:40):
Yeah, yeah. I think that'sexactly the question. And I
think lots of people, includingthe scientists who I
interviewed, are saying no. Thisone English or British
psychiatrist who I wrote about,Edmund sunooger bark, says this
search for a biomarker for oneparticular gene for a particular
pattern, neurological patternthat you can see on MRIs that is
associated with ADHD. It wasjust a red herring. We don't
(18:02):
need to look for that sort ofbiological marker, because what
matters is a child's distress.
And so if a child is feelingdistracted and they're upset
about it, that's real. That isour job, as the adults in their
lives, to help them deal withthat. And again, maybe
medication is the right way todo it. Maybe not, but it's a
very different situation thanthey need glasses, and so
(18:23):
they're gonna get glasses. Andso, yeah, I think sometimes the
research about biomarkers andgenes can get really
complicated, but I think what isimportant to take away from it
is that looking at ADHD assimply a biological disorder is
not not right and not the mosteffective and helpful way for
families to look at it instead,the way that a lot of the
(18:45):
researchers who I spoke tolooked at it is that it's about
a mismatch between a child'sspecific biology, their specific
brain, and their surroundings,the world they're living in,
whether that's their Family,their school, their society, the
technologies they're using,perhaps. And so how to deal with
that mismatch is a morecomplicated question. Sometimes,
(19:07):
again, medication is the bestway to do it, but sometimes
there are things that can bechanged in that child's
environment that can improve howthey're feeling, improve their
symptoms without any kind ofmedication.
I love that you describe themismatch between the brain and
the environment. I think that isabsolutely true in my
experience. I'm thinking ofexamples of my own family. My
(19:31):
sister was diagnosed with ADHD.
She struggled in school payingattention, but now she works in
sales. She does not have to sitand listen to lectures. She's
out and about meeting people,and she really thrives in that
environment. And then I thinkabout my first cousin, he also
was diagnosed with ADHD. Hecould not sit still in school.
It was really hard for him andhis family. He was put on a
stimulant medication. And nowfast forward 25 years. He's a
(19:53):
really successful fireman. Hewas just promoted to be a
captain. He thrives in thatenvironment. Environment. He
loves what he does. He is sosuccessful as a fireman, and to
me, that's a very clear exampleof a mismatch between where he
was struggling and anenvironment where he can
actually thrive. So I think it'svery true that a lot of stress
that a person with difficultywith focus and inattention may
(20:16):
have may be better served ifthey changed their environment?
Yeah, and those are fascinatingstories, and I think they really
hit home, and there's researchthat backs that up, the MTA
study, which I wrote about inthis article, a fascinating and
important study that followed agroup of children with ADHD
symptoms for more than 20 yearsinto young adulthood. It found
(20:40):
lots of important conclusionsabout ADHD and medication, but
one of the ones that I find mostinteresting was this study that
was done when the subjects werein young adulthood, like in
college and just out of college,and so many of them had found a
niche for themselves, whether itwas in school or out of school,
a new job, a major a way ofliving that was a better fit for
(21:04):
their brains, and suddenly a lotof their ADHD symptoms had gone
away, and they, in some cases,were questioning whether they
really had a disorder all along.
So I think that's really useful,and I think it is exciting when
families or when individuals canget to adulthood or adolescence
and find a niche where theyreally fit. One thing I hear
from a lot of families is thatif you're in third grade and the
(21:25):
environment where you're havingtrouble fitting in is a third
grade classroom, the option tobecome a firefighter is not
there for you right now, and soin that situation, sometimes,
yeah, the right thing to do isto look for medication or some
other more immediate treatment.
Just the fact that things aregoing to get better in the
future doesn't necessarily helpwhen you're sitting there in
that third grade classroom. ButI think it's still a really
(21:48):
useful idea for families to holdonto that this is not just
permanent biological deficit.
This is about a mismatch. Ithink that's really helpful to
know,yes, just the idea that just
because they have initiated amedication today, and then it's
useful for their child today. Itdoes not mean that they're going
to be on this medication for alifetime, by the way. Speaking
of a third grade classroomenvironment, have you ever heard
(22:09):
of give or Tully? By any chanceI haven't. No Tell me about you
might find him fascinating. Ifind him fascinating. He started
a school in San Francisco. It'sa Tinkering School, and it's
designed for kids who strugglein the classroom. And he takes
them outdoors, and he has thembuild things. And it's so
fascinating, if you look at hiswebsite, anything that they want
(22:29):
to create, he lets them createit. Oftentimes it's outdoors,
and there is even a child whomade a roller coaster. So he
lets them construct, design,create, and it's in a very
atypical classroom environment.
And while that model may be hardto scale throughout the country,
I do find it interesting thathe's thought outside the box to
(22:50):
help kids that have difficultyin school
thrive. Yeah, I think that'sreally useful. Both of my sons
have gone to tinkering classes,not as thorough going as the
school you're mentioning in SanFrancisco, but my sons love
them, and I think lots of kidsdo, and I think especially kids
for whom sitting in a desk allday, doing paperwork is not an
ideal setting, which I think ismost kids. The idea of making
(23:13):
school more active, moreengaged, more project based, I
think that's good for everybody,but I think especially for kids
who have a limited tolerance forboring stuff, I think that it's
a great solution. Now I want tobring
us back to talking about the MTAtrial, because I find the
results in this trialfascinating, and I know that in
(23:33):
over the years, this has beencited as one of the most useful,
well done ADHD trials. Can youexplain what the trial was and
what the ultimate findings were.
Yeah, so this was a study thatwas started in the early 1990s
at a moment where, as we weretalking about ADHD, diagnoses
were on the rise and Ritalin wasthe most commonly prescribed
(23:55):
medication, and there wasn't aclear answer in the field as to
whether Ritalin was actually thebest treatment for ADHD, or
whether there were behavioraltreatments or a combination that
would work best, and a group ofscientists from around North
America created this study insix sites where they recruited
young people, I think, 789, yearolds with ADHD symptoms, and
(24:18):
They divided them into differentcategories. Some would receive
medication, some would receivebehavioral treatments, some
would receive both, and somewould just be left on their own
to come up with the rightsolution for themselves. They
found two things. First of all,after 14 months, they found that
Ritalin was the most effectivetreatment for dealing with ADHD
(24:39):
symptoms. But then, after therandomized controlled trial was
over, they continued to followthese subjects in a long term
study, and they noticed that therelative effectiveness of
Ritalin was diminishing as themonths went on, and by three
years, by 36 months, there wasno difference. On average.
(25:00):
Urgent children who were in eachof these categories and so
continuing to make medication itlooked like did not actually
make a difference. They've nowcontinued to follow these kids,
as I was saying before, throughyoung adulthood, and they
continue to find that the oneswho have stayed on medication
consistently for all of thoseyears, they don't show any fewer
(25:21):
ADHD symptoms than those whonever started medication or who
started and stopped. And sothere's a lot of debate about
exactly what those results mean,but what a lot of scientists who
were involved in the studybelieve is that ADHD stimulant
treatments, Ritalin, Adderall,et cetera, they're effective in
the short term, but lesseffective in the long term. And
(25:43):
I think every individual'sresults might be different, but
I think it's a really importantidea for families to know about,
because it goes against the sortof glasses analogy, right?
Glasses continue to be usefulfor your entire life. Maybe you
need to increase yourprescription, but they remain
useful, but ADHD medications aredifferent, and that's I think,
because ADHD is different thanmyopia, and it's really useful
(26:06):
to know that fact, as you'retrying to find the right
treatment for yourself or foryour kids. I mean,
I find this really interesting,because from this MTA trial, I
believe the American Academy ofPediatrics has recommended that
the first line treatment forkids with an ADHD diagnosis,
should be starting a stimulant.
But I think it's a reallyimportant conversation piece to
bring up when we talk tofamilies about initiating
(26:27):
medication, is this very factthat, yes, we may notice a
difference initially, but overtime that effect wears off. When
I talk about this with friends,with family, they think, how can
this make sense? As you pointedout, because they seem to work
so well. But I also think thatwhen people have an ADHD
diagnosis, one explanation mayalso be that they find ways to
(26:48):
work around how they learn. Theymay learn better and catch up in
different ways. Maybe instead ofsitting down and reading, they
learn to be auditory listeners,or they find that they can learn
by moving and by walking, peoplecompensate for their
difficulties in other ways thatwe may not recognize.
Yeah, I think that's absolutelytrue, and I think the MTA study
(27:09):
is fascinating for lots ofreasons beyond that, they were
relatively effective at 14months and not relatively
effective at 36 months. One ofthe things that's fascinating
about it is that when you lookat the data, it wasn't that the
kids who had improved at 14months suddenly got a whole lot
worse at 36 months. It was thateverybody got a little bit
better. And that suggestssomething, right? It suggests
(27:30):
that ADHD symptoms, often askids get older, diminish. And
other studies that the MTAscientists have done with that
same group of subjects haveshowed that, in fact, there are
all sorts of fluctuations thathappen with symptoms over the
course of childhood. It's notthe case that everyone's just go
away, but it is the case thatthey go up and down a lot,
(27:51):
sometimes in unpredictable ways,through childhood, through
adolescence and into adulthood.
One fact that from one of thesestudies that I found really
significant is that only about11% one in nine kids who have
the symptoms at seven or eightor nine persistently hit the
clinical threshold of symptomsall the way through childhood
and adolescence. Everybody else,almost 90% their symptoms go
(28:14):
below that threshold for acertain period. Sometimes they
go away altogether, sometimesthey go away and come back and
so that doesn't just mean don'tworry about ADHD. It'll just go
away on its own, but it doesmean that again, this glasses
analogy is not a helpful one.
That doesn't happen when youneed glasses. It's not like for
a couple of years, your eyessuddenly get better. I
(28:35):
also find that a lot of parentseither they don't want their
kids on a medication or theystart their kids on a medication
they don't like the effects. Ithink that the results of this
trial give validity to the ideathat it is a choice, that you
can take a stimulant medication,but you also can approach the
diagnosis with Nuance.
Yeah, absolutely. One idea thatI have found really meaningful
(28:56):
is this idea that I think comesout of this new thinking about
diagnosis in general, that adiagnosis, I think some of us
have a tendency to want to clingreally tightly to a diagnosis,
to have it be the explanatoryforce in our whole lives, and
that I think it's much morepractically helpful and maybe
psychologically helpful to hangon to diagnoses, psychological
diagnoses lightly, right? Thisis one idea that might tell me
(29:19):
something about what is going onin my life right now, or my
child's life right now, but it'snot going to be the explanatory
force in their whole life. Maybethis is something that is true
now and won't be true in thefuture. Maybe it's going to go
away altogether. Maybe it'sgoing to get worse, but it's not
something to hang on tootightly. And when you do that, I
think it opens you up to reallyfollowing the evidence in your
(29:41):
child's life, right? Maybe thesesymptoms aren't so bad, and they
were bad a little while ago. Weshould try going off the
medication, as you were saying,like maybe you don't need this
medication on the weekend orover the summer. All of that, I
think, just not only leads tobetter practical outcomes, but
it also helps families thinkabout. This diagnosis in a much
(30:02):
healthier way, that this isn'tsomething that's like a
permanent deficit, a permanentdisorder that's wrong with your
kid. It is a situation that isserious, but that is about right
now, and if we don't hang on toit too tightly, things might
change. Things might get better.
That's a really positivemessage, I think, as well as a
very realistic one to give tokids and to give to families.
Absolutely the message that weevolve, things aren't forever,
(30:25):
things aren't permanent, Ithink, is a very helpful
message, because, to your point,earlier, labels have their use.
It can be helpful. It can makekids feel understood. It can
make parents feel like theirchild is more understood, like
they have a direction and a pathforward. But at the same time.
Sometimes I find that labels canbe limiting. I think the title
of my podcast, your child isnormal, stems from that idea
(30:47):
that sometimes these behaviorsthat we're so quick to want to
diagnose, to want to treat,oftentimes, these are just
normal childhood behaviors. Andkids aren't easy all the time.
They're difficult to raise. Theycan be feral. They can be wild,
and I think sometimes it's justnormal.
Yeah, I think that's reallytrue. And there's, I think
that's true on an anecdotallevel, like that I see in the
(31:10):
kids around me, I'm sure in themany more kids every day and
every week. But there's alsoresearch that suggests that, I
think there was this idea a fewyears ago, especially, that
giving a kid a biologicallybased diagnosis and saying
you've got this biologicaldisorder in your brain that
would diminish stigma, thatwould tell them it wasn't their
fault, it was just this thingthat was broken in their brain.
(31:31):
But there are lots of studiesthat say the opposite, and those
make a lot of sense to me, thattelling a kid there is something
broken in your brain does nothelp them feel better about
themselves and about theirpotential and their future, and
then instead telling them what Ithink is this much more
realistic story about ADHD as aproblem they've got right now
that might have to do with amismatch that is part of
(31:51):
something that we're all we allexperience to a certain degree,
some worse and more than others,and that might go away in the
future that is just gonna leadto a more psychologically
healthy outcome for them,they're not going to feel like
this is the thing that definesme, this is the thing that makes
me different from everybodyelse. They're going to think
this is a problem I've got totake seriously right now, but
(32:11):
it's not who I am.
So I want to ask you more aboutmedications and how they're
thought to work, and thepotential side effects that may
come from the medications. So myfirst question, why do we think
stimulants work in the firstplace?
They do tough? Said, so, youknow, these stimulants are all
based in amphetamines, and wehave known now for almost 100
years in this country thatamphetamines are a really
(32:33):
powerful drug, and they havegood effects, and they can have
some bad effects as well. Andthey kind of do that with
everybody. I think there's thisidea that some people in the
ADHD world believe it, thatthese medications are only
effective on people who have anADHD diagnosis. But that's not
the case. There are lots ofstudies that show anyone who
takes these medications oramphetamines in any way, they
(32:55):
have some version of the sameresponse, which is, they can
focus more. They don't careabout distractions. They have a
much higher tolerance for boringstuff. The Times, historically,
when we've used it have beenlike with people who are doing
incredibly boring jobs, soldierswho have to stay up all night
just staring at the sky,watching for planes, long haul
(33:17):
truck drivers, these are allpeople for whom amphetamines
have been really useful becausethey let you focus on things
that are kind of boring. HighSchools, for instance, is also
kind of boring, and so it makessense that these medications
would help kids focus, but therehave always been downsides to
amphetamines, and I shouldclarify that the medications
that we're giving kids now havea lot of safety features that
(33:40):
make them less prone to abusethan amphetamine medications in
the past, but it's still thesame basic drug, and it's always
had downsides. So a lot of theyoung people who I spoke to said
they felt like it changed theirpersonality, they were less
social, they were less able toengage. All of which makes
sense, right? If you're onlyfocused on the one thing in
(34:01):
front of you, you're not asfunny, you're not as fun, you're
not as spontaneous. And so Ithink a lot of families, a lot
of kids, say they don't like theeffects, and a lot of them stop
taking it over time. But in theshort term, in terms of managing
those symptoms, diminishing thatdistractibility, letting you
focus on the stuff you'resupposed to focus on, on
(34:24):
average, they're reallyeffective with lots of people,
but it does not make yousmarter, correct, it does not
change your IQ. So in essence,what you're saying is the
medications work by helping youfocus on boring tasks. They make
boring tasks less boring, andyou're able to sit and focus and
focus and do things that youmight not want to do, or a less
preferred task.
That's right. Sometimes amongcollege students, anyway, they
(34:46):
have the nickname smart pills,and they are not smart pills.
They don't make you smarter.
There are lots of studies,including some that I read
about, that show that incontrolled situations, when
scientists divide kids up intothose who receive the
medication. And those who don't,the ones who receive the
medication, do behave better.
They act out less, they focus ontheir work more. But when you
(35:07):
test them on how much they'velearned or how able they are to
answer complicated questions,there is no real difference
between the kids who receive themedication and who don't, and
we're not entirely sure why thatis, but the theory that makes a
lot of sense to me is to thinkthat we should be thinking about
these stimulant medications asworking on our emotions and our
(35:27):
motivation more than on ourcognition. It changes the way
you feel about the work thatyou're doing. And that's not
nothing. Emotion is certainlyimportant, and it's a big deal
for every kid, but it's reallyvaluable, I think, to understand
that's what's happening. Whatwe're doing is not making
ourselves smarter, not makingourselves better able to do
these tasks, it's changing theway we feel about the work we're
(35:49):
doing. Sometimes temporarily, Ifind that a lot of parents worry
that their kids are more likelyto be to be addicted to these
medications over time, that itmight be a gateway drug to more
drugs in the future. So Iappreciate that you mentioned
that these drugs are formulatedto keep kids from growing an
addiction to the stimulantmedications. But there are some
real side effects, and you touchupon a lot of them in your
(36:11):
article. Can you mention some ofthe real side effects that you
noticed that might surprisepeople listening?
Well, the side effect that theMTA study pointed out, which I
think is a surprise to a lot offamilies, is about height
suppression. And again, there'sdebate in the scientific
community about how consistentthis result is, but in the MTA
(36:31):
study, at least children whoconsistently took stimulant
medication over time were aboutan inch shorter than their peers
who didn't take thosemedications. And initially, the
researchers thought that thiswas just a short term, temporary
difference in height and that itwas going to change as kids hit
(36:52):
puberty. But it doesn't,according to the MTA, and when
they now look at the adults, theones who have consistently taken
medication are still an inchshorter than their peers. There
are lots of people who say thatis a small price to pay for the
benefits of medication, but itis absolutely something I think
that kids and families should beaware of, and I think it's
another reason to think aboutstimulant medication, not
(37:15):
necessarily as a long termsolution, but as a short term
solution, as something to tryfor a while to get through a
crisis period, but it's, onaverage, at least a significant
effect, according to the MTA oflong term stimulant use.
Yes, and to your point, I thinkthat takes me back to the idea
of making it a shared decisionthat you want parents to
understand the full potentialbenefits and the full potential
(37:37):
negatives. As you pointed out,an inch may not be much to
somebody who's struggling withbehavioral issues with their
child, and they feel like thestimulant makes a big difference
in their quality of life, in thelife of their child and the life
of their family. But for somefamilies, that's important, and
I think that's reallyinteresting to point out, I
agree. I also find too it'sstressful for families that kids
(37:58):
have a diminished appetite thatcauses a lot of stress. For a
lot of kids, when the medicationwears off, they seem more
irritable. So they may get thebenefit of a focused child for a
few hours, but then as themedication wears off, that can
also be stressful for families,some kids suffer from insomnia,
so I find that they may be on astimulant during the day, but
then they end up needing anothermedication or something else to
(38:20):
help them sleep at night. Andfor kids that have tics, once
they're started on a stimulantmedication, those tics may
exacerbate so there are a lot ofside effects to these
medications that I think it'sworth bringing to light, just so
that parents can take all thesefactors into consideration.
Yeah, I think it's a seriousmedication for sure, and it
doesn't simply make it easier topay attention and not have any
(38:42):
other effects. I felt I learneda lot from talking to the young
people, mostly adolescents, whohad taken the medication. And
some of them were more positiveabout the experience than
others, but all of them saw itas a series of trade offs. The
one word a few of them used wasa sacrifice. This is not
something I like doing, but Isee it as a sacrifice that I
have to make for the future. Andthe adolescents themselves have
(39:04):
these very nuanced approaches,like I take it on certain days
when I need to feel one way orneed to do certain tasks and not
on other days. There was onegirl I spoke to who it was like
the end of summer, and she wasabout to say goodbye to her
friends who were all going backto college, and she said she
didn't take it that day so thatshe could have the more deep
sort of emotional connectionwith sadness of her friends
(39:27):
going away, because she knewthat if she was on the
medication that day, there wouldbe something diminished about
her emotional responses. So Ithink really listening to kids,
especially adolescents, as theyget more expressive about what
their experience is with thatmedication, how it makes them
feel in different situations,that's really important. And I
think there's sometimes apressure on families that the
(39:48):
only conversation should be likethe adults telling the kids to
take these medications and makesure you do it on time. And I
think when you can have a realconversation about what the
pluses and what the minuses areof taking the medication, you.
It's going to be a much moresuccessful experience. So
this is really helpful, and Iwant to talk now beyond
medications. In your article,you highlighted how changing a
(40:09):
child's environment may easesymptoms. Can you give an
example of what that might looklike? I want to make sure
families understand the otheroptions that are out there
beyond medication.
So there are lots of behavioralinterventions, some whole
programs that have particularnames and some that are just
more ad hoc. My understanding isthat there isn't one that,
(40:31):
through a rigorous test, beenproven to be more effective than
medication over the long haul.
But I don't think that meansthat environmental changes can't
be very effective. I just thinkthey have to be more
individualized and spontaneousand reflective of the individual
child. Changing the dynamic athome can often make a big
difference when kids feel moreaccepted and understood, when
(40:55):
they feel like theirdistractibility or their
problems staying focused aresomething that they can work on,
sometimes with little fixes likepost it notes and lists on the
wall and schedules and that thisis something that they can get
better at with help and witheffort. I think that's can often
lead to really positive changes.
And similarly, at school, thereare ways that assignments can be
(41:18):
more or less distracting whenchanges can happen in the way
that a classroom is set up whereyou do homework, when that can
change, sometimes in small ways,it can really help. I don't
think there's a magic bulletwhere we can say this is the
behavioral intervention that'salways work, but I do think that
changing environments can help.
Yes, Iespecially find that for the
young boy, 789, 10 years old,who's got a lot of energy and
(41:41):
can't sit still in theclassroom. I'll often advise
parents to talk to teachersabout making sure they have
their recess, making sure theymove their bodies, maybe doing
jumping jacks in the middle ofclass, taking 10 minutes before
school starts to run sprints,similar to having a puppy. You
gotta get their energy out orthey're not gonna sit still.
Totally Yeah, I think that'sabsolutely right. And I think
(42:04):
again, it comes down tocommunication and understanding
between the child, parents andideally, a teacher in a school,
and that when all of those threeindividuals are able to work
together and to see this as aproblem that is real, but that
is solvable. You can often comeup with some really creative
solutions. And I think that ideaof thinking of it as a solvable
(42:28):
problem is psychologicallyreally positive for the kids,
because they don't think, Oh,this is my problem. This is a
disorder that I've got thatmeans I'm different, that means
I'm weird, that means I'mbroken. Instead, they're like,
this is something that we cansolve and that we're all going
to solvetogether. Absolutely I do feel
like this is a group effort. Ifind a lot of parents come to me
either stressed because theyfeel like the teacher is asking
(42:49):
for the parent to come to me torequest medication, or I find
often that parents are relievedthat their teacher understands
that the child is havingdifficulty, works to make
accommodations for thatparticular child. Maybe they're
an experienced teacher, orthey've had a child themselves
that struggled, and that is sorelieving for families when they
feel like their child isunderstood for sure.
(43:14):
So as we wrap up,if you could change one thing
about the way we talk aboutADHD, what do you want parents
to better understand?
I think it's really useful forparents to understand that an
ADHD diagnosis is not a sort ofpermanent and essential thing
about a child, that it does notindicate that this child has a
(43:37):
brain defect that is permanentand is never going to change,
never going to go away. And Ithink that's important for a
couple of reasons. I think it'simportant because it's true,
because I think all the evidenceis there that we can't say that
for sure about ADHD, I thinkit's important because on a
practical level, it's going tolead to better solutions. It's
(43:57):
going to push parents, I think,to find solutions and to work
with their kids and theirpediatricians and their kids
teachers to find good solutions.
And I think it's also reallyimportant psychologically, that
it gives the message to childrenwho I think are really the ones
we need to care about the mostin this dynamic, that they are
not broken, that they don't havethis deficit that is never going
(44:20):
to go away, that they have aserious situation that they need
to take seriously with theirfamily's help and with their
school's help and with theirpediatricians help. This is not
the thing that's going to be themost important fact in their
lives. This is going to be onething that is worth dealing with
and worth thinking about, butit's not going to be the thing
that defines the rest of theirlives.
(44:40):
And if people want to read moreabout what you do, where can
they find you? Ihave a website at Paul tough.com
that has links to my stories andmy books, so that's a good place
to start.
Paul Tough, thank you so muchfor the research that you do,
and I really appreciate youtaking the time to come on your
child as normal.
Thank you so much. Thanks forinviting me on.
Thank you. So much. Thanks.
(45:01):
Thank you so much for listeningto my conversation with Paul
Tough and for joining me for thespecial 200th episode. And if
you enjoyed today's episode, itwould mean the world to me if
you could do two things, sharethis episode with a friend or
another parent who might find ithelpful, and leave a five star
review wherever it is. Youlisten to podcasts, it really
helps other parents find theshow and join this community.
(45:22):
See you next Monday. You.
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