That Times piece about ADHD

This weekend there was a 10,000-word feature in the New York Times about ADHD, written by Paul Tough. So I’m going to talk about it.

It’s… uneven. I’m coming at this as a science reporter and editor who is neurodivergent and does not (as far as I know) have ADHD. This isn’t meant to be a comprehensive review, it’s just what jumped out at me.

For starters, let’s look at the sources with ADHD whom Tough spoke to. He didn’t speak to any women, girls, or nonbinary people with ADHD. He interviewed two teenage boys with ADHD, Cap and John. They’re both from the same baseball team at the same suburban high school somewhere on the East Coast–a very narrow basis for representing kids with ADHD more broadly. We don’t know their race or socioeconomic status, although we know that Cap grew up in an “affluent neighborhood” and his parents enrolled him in summer SAT prep classes. 

Tough spoke to only one adult with ADHD, researcher Edmund Sonuga-Barke. Tough writes things like “It’s still not entirely clear why the simple act of providing a diagnosis of A.D.H.D. seems to have such profound effects on some children and their families.” You know how you could clarify that? Ask adults with ADHD who were diagnosed as children about their experiences! 

More critiques: 

• “Is a patient with six symptoms really that different from one with five?”

  • Yes, I wonder about this all the time too. But this is true for depression and anxiety too, and it doesn't mean they're not real or worth treating.

• Of course ADHD is not caused by a single biomarker. The failure to find a biomarker doesn't mean anything about whether ADHD has a biological basis or not. Biology is more complex than that.

• “last year, a study in The American Journal of Psychiatry found that even a medium-strength daily dose of Adderall more than tripled a patient’s likelihood of developing psychosis or mania. A high dose increased the risk by a factor of five.”

  • Presenting relative risk only (without absolute risk) is not best journalism practice because it “omits important context and can thereby make the stakes seem more extreme.” 3x a risk of 1 in 1,000,000 is different from 3x a risk of 1 in 100.

• “’But in the long run, you’re going to be shorter. How many kids would agree to take medication? Probably none.’” [quote from James Swanson]

  • Has Swanson talked to children? How tall they’ll be as an adult is not usually one of their top concerns. It’s famously hard for them to even conceive of what it will be like to be an adult. Moreover, only one gender of kid is told that they’re worth more if they’re tall—perhaps Swanson forgot that not all kids are boys?

• “That might sound a little mushy — that the point of A.D.H.D. treatment is to help you build relationships and improve your self-esteem, rather than the more scientific-sounding goal of repairing your malfunctioning brain.” 

  • Minus the ‘malfunctioning’ part, which is pure and unneeded ableism, these are the same thing! Self-esteem is located in the brain! 

• “Does portraying A.D.H.D. as a “disorder of the brain” actually reduce its stigma? Might it not, in fact, increase a young person’s sense of shame and isolation to be told they have a brain disorder?” 

  • Sure but I think the ‘disorder’ part is a lot more stigmatizing than the ‘brain’ part! Yet Tough never fully breaks free of seeing ADHD as a disorder.

• Tough suggests that under the new conceptual model of ADHD, families “can consider whether there are changes in [a kid’s] situation, at school or at home, that might help alleviate [their] symptoms.” 

  • Yes! That’s usually the first thing families do already! They are already doing that! This is not a new idea!

Things I want to cheer “YES!” for: 

• “What matters instead, he says, is the distress children feel as they try to make their way in the world.”

• “It considers those symptoms not as indications of neurological deficits but as signals of a misalignment between a child’s biological makeup and the environment in which they are trying to function.”

  • YES and this is called “the social model of disability.” Tough should mention this—at length, I’d argue—and credit disabled activist Mike Oliver, who invented the term more than 40 years ago.

• “The experience of taking medication might feel quite different if it was presented to them not as a medicine to fix their defective brain but as a tool to make an inhospitable environment more tolerable.”

Things I want to know more about:

• “Statistically, most adolescents don’t stay on stimulants for more than a year.” 

  • This is fascinating to me, but not nearly enough information. Where is this statistic from? Is there more than one study? What is the actual percentage for “most”--is it a slim majority, or higher? Does the study (or studies) ask adolescents or parents or prescribing physicians for reasons? Is anyone studying this in more detail? 

• Tough floats the possibility that ADHD symptoms fluctuate. There’s actually published evidence that they do–in people with a menstrual cycle (see this SciAm piece). Yet Tough does not mention this, or menstrual cycles, at all. He only interviewed one woman for the piece by email; he didn’t speak to her. (He quotes another woman who is a researcher, and a woman who was a subject of a study, but these quotes are from scientific papers.)

• Tough cites Joel Niggs’s research on ADHD subtypes to say that kids “whose A.D.H.D. symptoms are accompanied by intense anger, are at much higher risk of negative outcomes than those with A.D.H.D. symptoms alone... Those patients, representing about a third of children diagnosed with A.D.H.D., need early attention and comprehensive treatment — most likely including medication.” 

  • I want to know so much more! If this is robustly supported, it sounds like it has very clear and obvious clinical implications. A clear way to identify patients who benefit more from medication and need more early attention is VERY actionable. What do other researchers in the field think of Niggs’s subtypes? Why have I never heard this before? What’s the quality of the evidence that a full third of kids with ADHD fall in this category?

Finally, Tough concludes the piece with the hope that a new (it’s not new) conceptual model of ADHD could help kids with ADHD envision a brighter future for themselves. You know what’s a great way to help kids with ADHD see themselves and their futures positively? Talk to adults with ADHD! 

I am, however, down with the very last thing Tough says. Except I think it’s not just kids with ADHD, it’s all of us who need to keep remaking the world to fit ND brains, rather than the other way around.

What I’m reading: James, by Percival Everett. I’m absolutely devouring this.

Art that’s giving me life: Shing Yin Khor’s illustrations. You can find their Patreon here.

Thanks for reading!

Julian

Bluesky

www.juliannowogrodzki.com

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