As diagnoses of A.D.H.D. and prescriptions for medications hit new record highs, scientists who study the condition are wrestling with some fundamental questions about the way we define and treat it. More than 15 percent of American adolescents have been diagnosed with A.D.H.D., according to the Centers for Disease Control and Prevention, including 23 percent of 17-year-old boys. A total of seven million American children have received a diagnosis.
Normally, when a diagnosis booms like this, it’s because of some novel scientific breakthrough — a newly discovered treatment or a fresh understanding of what causes the underlying symptoms. I spent the last year interviewing A.D.H.D. scientists around the world for my magazine article, and what I heard from them was, in fact, the opposite: In many ways, we now understand A.D.H.D. less well than we thought we did a couple of decades ago. Recent studies have shaken some of the field’s previous assumptions about A.D.H.D. At the same time, scientists have made important discoveries, including some that are leading to a new understanding of the role of a child’s environment in the progression of his symptoms.
At a moment of national concern about our shrinking attention spans, this science suggests that there may be some new and more effective ways to help the millions of young people who are struggling to focus.
Below are the key findings from the new research.
A.D.H.D. is hard to define — and recent science has made it harder, not easier.
A.D.H.D. has always been a tricky condition to diagnose. One patient’s behavior may look quite different from another’s, and certain A.D.H.D. symptoms can also be signs of other problems, from anxiety and depression to childhood trauma and autism spectrum disorder. Twenty years ago, researchers thought they were on the verge of ending that controversy by finding a distinct “biomarker” for A.D.H.D. — a single gene that would reliably predict the disorder, or a physical difference in the brain that you could spot on an M.R.I. But today scientists acknowledge that the search for a biomarker has mostly come up empty, which means the diagnosis remains fluid and somewhat subjective.
Adding to the confusion, a study published last October found that only about one in nine children diagnosed with A.D.H.D. experiences consistent symptoms all the way through childhood. More often, the researchers found, symptoms come and go, sometimes disappearing for a few years, sometimes returning. Together with other research, this study has led some in the field to conclude that our traditional conception of A.D.H.D. as an inherent biological fact — something you simply have or don’t have, something wired deep in your brain — is both inaccurate and unhelpful. A new model considers A.D.H.D. differently: not as a disorder you always have in some essential way, but as a condition you experience, sometimes temporarily.
Medications like Adderall and Ritalin can have a positive effect on children’s behavior – but the results often don’t last.
The biggest long-term study of A.D.H.D. treatments found that after 14 months of treatment, a daily dose of Ritalin did a better job of reducing children’s symptoms than nondrug interventions like therapy or parent coaching. But then the effect started to fade, and by 36 months, the relative benefit of the drug treatment had disappeared altogether. The symptoms of the children in the medication treatment group were no better than those of the ones assigned to behavioral interventions — and no better than a comparison group that was given no intervention at all.
The medications can improve students’ behavior in the classroom — but they don’t seem to help them learn.
Medications like Ritalin and Adderall reliably improve students’ behavior — at least in the short term — but they don’t seem to do much to improve academic achievement. Research suggests that on medication, children are working harder and faster but not more effectively. So when it comes time to take a test, they haven’t actually learned anything more.
Still, it’s a puzzle: If A.D.H.D. medications don’t improve academic performance, why do so many students and their parents think they do? Researchers investigating this question have found that drugs like Ritalin and Adderall mostly work on your emotions, not your cognition. They don’t make you smarter, in other words — but they make you believe you’re smarter by increasing your emotional connection to the work you’re supposed to be doing.
There’s some history to this. Today’s leading A.D.H.D. medications are all versions or derivatives of amphetamine, and ever since World War II, a main attraction of amphetamine pills is that they make boring activities (watching for German planes, doing endless loads of laundry, driving a truck across the country) seem more interesting. Today Ritalin and Adderall may be having the same effect for high school students — making boring school work seem temporarily fascinating.
There is no clear dividing line between those who have A.D.H.D. and those who don’t.
Rather than conceiving of A.D.H.D. as a black-or-white, yes-or-no diagnosis, many researchers now believe that it’s more accurate to consider A.D.H.D. symptoms as existing on a continuum. As the British researcher Edmund Sonuga-Barke said to me: “There literally is no natural cutting point where you could say: ‘This person has got it, and this person hasn’t got it.’ Those decisions are to some extent arbitrary.”
On one end of the continuum are children who could probably get an A.D.H.D. diagnosis — but also might be fine without one. On the other extreme are cases that are much more serious. Joel Nigg, a researcher in Oregon, has identified one group of children — about a third of the diagnosed total — whose A.D.H.D. symptoms are accompanied by intense anger. They are at much higher risk of future problems, including school dropout, criminal behavior and early death. We should put our treatment focus on those children, he says, and consider other approaches for those with less serious cases.
Changing a child’s environment can change his or her symptoms.
A.D.H.D. is usually portrayed primarily as a medical condition — a neurodevelopmental disorder with a genetic cause — which is why we often look first to medication to treat it. But researchers are now discovering that A.D.H.D. symptoms can be highly responsive to the environment as well. When the surroundings of a person with an A.D.H.D. diagnosis improve — a more engaging classroom, a more stimulating job, a more congenial home life — his symptoms often improve as well.
These findings are leading some researchers away from the traditional “medical model” of A.D.H.D., which sees the brains of people with A.D.H.D. symptoms as biologically deficient, and toward a new model that considers A.D.H.D. primarily as a mismatch between a child’s unique brain and his environment. Medication can still be useful in helping to resolve those mismatches, but changing the environment can sometimes work just as well.
When A.D.H.D. is bad, it’s bad. And when it’s bad, medication can help. But many children and parents have been led to think of A.D.H.D. as a permanent malfunction, when in fact it might be better thought of as a temporary misalignment, brought on by external forces as well as internal ones. Finding a solution for that misalignment is important, especially for a family in crisis. But identifying the right solution starts with having a more accurate understanding of A.D.H.D.
Paul Tough is a contributing writer for the magazine who, for the last two decades, has written articles and books about education and child development.
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