Ep 200! Rethinking ADHD: Diagnosis, Treatment, and What Families Should Know - A Conversation with Paul Tough

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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Transcript

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Hello listeners. This is Dr Jessica Hochman. I'm excited to share that I am now booking sponsorships for your child as normal for this fall. If you have a product, service or a message that you think our listeners would benefit from, whether it's for parents, kids, healthcare or family life in general, this could be a great opportunity. You can find details on how to sponsor by checking the show notes. Just click the link that says how to sponsor an episode, and I'll let you know for a good match and get back to you. Hi everyone, and welcome back to your child. Is normal. I'm your host, Dr Jessica Hochman, and today is a really special milestone. This is our 200th episode, so I just want to take a moment to thank you, whether you've been listening from the very beginning, shout out to my mom and my mother in law, or you just found us. Thank you for being here, for sharing the show with friends and for helping us to create a community that celebrates the fact that so much of what kids go through is Well, normal. And for this big episode, I couldn't think of a better guest today, I'm talking with Paul Tough. He's an incredible journalist who's writing you've probably seen in places like the New York Times Magazine, The Atlantic and GQ. Paul's most recent cover story for The New York Times Magazine. Have we been thinking about ADHD? All wrong? Has sparked so many important conversations about how we understand and support kids with ADHD. So in our conversation, we talk about what drew Paul to this topic, how his reporting challenged what he thought he knew, what this might mean for parents, teachers, and really, anyone who cares about kids and how they learn and thrive. I am so excited for you to hear this conversation. So without further ado, let's dive in, Paul Tough. Welcome to your child as normal. Thank you so much for being here. Thank you. Great to be here. So the recent article that you wrote in New York Times Magazine has gotten a lot of attention. You asked a very poignant question, ADHD, have we been thinking about it wrong? First, maybe describe what drew you to focus on ADHD and researching ADHD, I think I became interested in it through two directions at once, and the more immediate one was that I'm the parent of two boys, one is now 10 and one is now 16, so they are in the ADHD demographic, for sure. And a few years ago, I just started noticing that lots of other parents at their schools and elsewhere were worried about their kids' attention span and were thinking a lot about ADHD as a potential diagnosis, so I felt like it was in the air. And then, more broadly, for the last few years, I've also just been interested in attention as a more general question, why is it so hard for so many of us to pay attention? It certainly feels like it's related, in some way, to the changing technologies in our lives. But it felt like there's something else going on why so many kids and adults were struggling with attention, and so this ADHD felt like it intersected with both of those questions. I found so much of what you talked about in your article very interesting, especially as a pediatrician, because I am definitely noticing more and more families come to me questioning whether or not their child has an ADHD diagnosis. And while it's clear that the diagnosis of ADHD exists, and I do see kids benefit from medications, I do worry that we're in an era of over diagnosing. Is that similar to what you found in your research? I think it's really hard, certainly for me as a journalist, to say whether we're over diagnosing ADHD or not, but something is changing. One of the things that's really striking about the ADHD diagnosis rate is that it at least among children, it hasn't suddenly spiked. It has been going up steadily and consistently for 30 years. So one of the things that I did for my reporting is looked back at the way that ADHD and Ritalin the main medication at the time, were being covered in the media in the 1990s literally 30 years ago, and it was very much the same as it's often gets written about now. Like, why is this happening all of a sudden? Why suddenly are diagnosis rates going up so much? And when you look at the Centers for Disease Control Data over those 30 years, it really is just this steady increase. So it feels like a crisis at any given time. It feels like a sudden boom, but actually it's a very consistent rise. So I do think there's something going on, but I don't think it's particular to this moment. So I find the actual percentages and numbers really interesting to hear. Can you describe to the audience how many kids were diagnosed with ADHD many years ago compared to where we are today. So in the 90s, that first flurry of media attention came to ADHD. It was because the total number of young people diagnosed with ADHD had gone up from about a million to about 2 million. And in the last few years, we've gone up from 6 million to 7 million. So there has been this consistent rise, and that's 7 million children who are now, according to the CDC, have had an ADHD diagnosis that represents 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 among 17 year old boys, it's like 21% of them have received and they paid. ADHD diagnosis. So big numbers for all children, but especially large for certain categories, especially adolescent boys. What do you think is behind this constant surge in diagnosis? Do you think that we're recognizing cases that weren't previously diagnosed? Do you think it has to do with the change in society, as you mentioned, we're in this world now that's much more digitized, or do you think there's something else going on again? I think it's really hard to say from the numbers. My guess, though, is that there's an all of the above quality to it. So certainly, I think the change in technology and with adults, I think the change in the way that we work has led to problems with attention for all sorts of people, and that an ADHD diagnosis can seem to a lot of adults and parents like the right way to deal with that increased distractibility. I do think there are certain advantages that come with getting the diagnosis, both practical advantages, but also, I think sort of psychological advantages. You can feel more understood, more accepted, I think, when you get this diagnosis. So I think that's appealing to certain families and certain individuals. But I think there's also probably some element of social contagion. If you look at the way that different diagnoses have increased at different times, especially psychological or psychiatric diagnoses, there is this pattern where at certain periods, especially when news of diagnoses can travel, as it does these days, through social media, you can get this sort of increase because people just hear about this diagnosis. People can disagree whether that's because they're now receiving this accurate information that helps them understand the reality of their lives, or whether there's something about our suggestibility that when we're feeling a certain type of distress, when we're feeling upset or distracted or having hard time fitting into a particular situation, if someone comes along and says, what you've got is x, and lots of other people have x, and there's this boom in x, it can be a very powerful suggestion that is Your situation as well. So what percentage of the reality of this increase in diagnosis belongs to each of those categories? I don't think it's possible to say, but my guess is that there's some of all of that going on. So what I have to say definitely notice at work is that families or patients will come to me with a sort of self diagnosis. With ADHD, they found a quiz online. They take the questionnaire and they say, oh my goodness, all of these symptoms are now explained. My distractibility, it's difficult for me to concentrate on lectures in school. And they say, This is my issue. I figured out why I've had such trouble, and I have a hard time with this to some degree, because while I definitely recognize there are many kids that have a true difficulty with focus. I also think to a large degree for me, this feels very normal. I remember being in college having a lot of difficulty paying attention to my history class, really struggling listening to the physics lecture. So I think what I worry about is how we are diagnosing ADHD in our current environment. And my question to you is, from your research. Do you have any critiques or thoughts on how we are currently diagnosing? ADHD, again, I think it's really hard to say, and I'm glad that you and other pediatricians are the ones on the front lines, and not me trying to figure out for any individual family or child what the right approach is, because it's really difficult to say. So there is this movement that I'm really interested in in psychiatry in general, questioning the whole notion of diagnosis. There's a book that just came out, actually, since my article came out, called the age of diagnosis, by Suzanne O'Sullivan. There's another one by a psychiatrist named Benjamin Leahy that looks at the idea of sort of categories of psychiatric disorder. And both of these researchers and lots of others are questioning the way we think about diagnosis, I think that what they're saying is that there is this human tendency to want to say, I've got x, I've got y. This is, this is the thing that explains my whole life to me, and often receiving a diagnosis like that doesn't turn out to be a positive thing. It actually is disempowering to a lot of people to be able to categorize themselves like that and to have others categorize them. And so they're suggesting that we look at psychiatric distress in another way, as sort of a spectrum that everyone is on, as a collection of psychiatric symptoms that often don't need to be put into certain boxes, but still need to be taken seriously. And this is, I think, where for you as a pediatrician, and for lots of frontline clinicians, it gets really complicated, because even though I'm sometimes skeptical about individual diagnoses of ADHD, I am not in any way skeptical about the underlying distress that individuals feel. So I think there is real distress among a lot of kids, a lot of families, a lot of adolescents and a lot of young adults as well, feeling like their minds are not in their control, that their attention is not in their control, that they are often really miserable as a result. And so I think what's tricky is to take those symptoms and take that distress seriously and say this is something we need to deal with. Yeah. But to also say that maybe an ADHD diagnosis is not the best solution to the distress that any individual is feeling. So that's where I come down. And I think it's a tricky kind of conversation, as I'm sure you experience every day, to have, between a clinician and a 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 that it's shutting off those conversations. And so when you have this opportunity for a family and a clinician to have this conversation about what is wrong in your life, what is not working, what could we do to change things? Instead that just gets short circuited and it is, yep, you've got this disorder. It's a biological disorder. There's just something wrong in your brain. That's all we need to know. You're broken, and we've got the fix, and that fix is often the pharmaceutical one, and then that's the end of the conversation. You start taking these medications, and you don't need any other help. You're now on your own. And I think for some kids and families, that ends up actually being a good solution. But for many others, it's not. It's not the best solution. And I think part of why it's not the best solution is that it can cut off this opportunity for a family to really have these deeper conversations about what that child needs to be happier and to function better. I have so many thoughts to what you just said, but first, I want to go back really quickly. Can you explain to everybody in your research what is the current gold standard for diagnosing ADHD? The way that clinicians are supposed to diagnose ADHD is using the Diagnostic and Statistical Manual of Mental Disorders, the DSM. We're currently at the DSM five, and that gives clinicians like you a checklist of different symptoms, some for inattentive ADHD, some for hyperactive or impulsive ADHD. And there's just this checklist. I think there are nine potential symptoms in each category, and if you have six in either category, you can be diagnosed with ADHD. There are certain other facts that need to be met. Then you have to hit a certain level of impairment. They have to the symptoms have to have existed for a certain amount of time. They can't be better explained by another psychiatric disorder. So there is this sort of very scientific method that you and others are supposed to use. From my point of view, it sounds really hard to do, because a lot of those measures are very subjective. You know, it's like the word often shows up a lot, like, are you persistently impaired? You know, if you hit six symptoms rather than five symptoms, you can be diagnosed. My guess is that for a lot of clinicians, there's a lot of subjectivity, there's a lot of guesswork, and is this really the best approach, but that is for now, at least the gold standard, the DSM five. What I really appreciate about your research and what you've come to find and talk about is the nuance here. Because I do agree that when families come to talk to me, and maybe their child just received a diagnosis of ADHD or they're concerned, that's the potential diagnosis. I do find that some families come assuming that their child will need a prescription to make their condition improve. But to your earlier point, I find that people are craving conversation, that they want to know what options there are. And if you talk to them about other ways to go about it that don't involve medication, sometimes that's more what they are looking for. And yes, I agree that for some kids, medication seems to be the right way to go for this moment in time. But what I'm finding really interesting is that it's really 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 real struggle for a lot of clinicians, is to be able to take the time to listen to what patients are saying and to find the right individual solution for that family. And you know, there's a real attraction, I think, both for families and for clinicians in pharmaceuticals, in that they're a simple answer, right? They're a straightforward answer, and the alternatives are often kind of complicated. Like, let's try different ways to organize your life. Let's think about school in a different way. Let's think about family dynamics in a different way. Like, that's hard stuff, and so I think, I think really listening to those families and helping them when they do want to have that conversation is crucial when it can happen. When I was in my medical school training, I remember there was one psychiatrist who explained treating ADHD with stimulants, as giving a child who has difficulty seeing and then you give them their glasses. And this conversation came up about when to take medications. When a child is prescribed a stimulant medication, do you continue it through the weekend or just give it to them during the school days? And this particular doctor said you absolutely want to encourage parents to give a child their medication over the weekend, because imagine not giving someone their glasses every day. That's unfair. A child's not going to be seen clearly. They're not going to have opportunities to learn over the weekend. Absolutely, we should encourage families to give their child their medication every single day. And what I've come to evolve in my thinking as I've been practicing as a pediatrician that. That's not the case that I really leave it to the families. I ask the families, what do you want? What does your child want? Do they just want the medication for school during the time when they really need to focus? And do you want to give them a weekend holiday? And that's okay, and I find some parents like that approach, and some parents want it on the weekend. They need it for their kids baseball practice or whatnot. So what I'm trying to say is, for myself, I found that with families, I approach it in a much more individualized manner, that it's not a one size fits all. I think that's great, and I think that's hard for clinicians to do, but I think it's really valuable when you can take the time to have that kind of conversation. I have also heard that glasses analogy a lot, and I think there's something valid and valuable about it, because it does diminish the stigma that I think some families and some kids can feel about taking medication. But it also is very much a biology first explanation of ADHD, right? It is expressing ADHD as just a thing that went wrong that happens in our eyes and our corneas and our retinas that like something changes in our cones, and it it can't really be changed back, and you just have to deal with it. And then there's a way to deal with it that's really simple and straightforward glasses. And my reading of the current research around ADHD is that's not accurate in terms of ADHD, that it's not simply a biological disorder. I think there's still an ongoing debate within the scientific community, but the attempt to find a simple test, like an eye test, that can say this person biologically has ADHD, has not been very successful, despite a lot of attempts in the past to find what they call a biomarker for ADHD. And I think that one of the things that I think culturally has changed over the last few decades is that many of us have become very attached to a biological understanding of psychiatry. In the past, in the Freudian era, we thought this was your psychological distress. Was all about your relationship with your mother, et cetera, et cetera. Now, I think we tend to look for biological explanations, and there's certainly some biology at play when it comes to ADHD, but it is not as simple and straightforward as what happens to your eyes when you need glasses. And so I think accepting that complication will lead to better treatment and better conversations about what ADHD is and how to treat it. So just to expand on what you're saying, if I understand correctly, you're saying that if we're looking for a gene or a specific biomarker to actually diagnose yes or no your child has ADHD, we're likely not going to find it. And I think the bigger picture is, does it actually matter if a child has the symptoms of ADHD? Do we actually need to find a genetic biomarker? Yeah, yeah. I think that's exactly the question. And I think lots of people, including the scientists who I interviewed, are saying no. This one English or British psychiatrist who I wrote about, Edmund sunooger bark, says this search for a biomarker for one particular gene for a particular pattern, neurological pattern that you can see on MRIs that is associated with ADHD. It was just a red herring. We don't need to look for that sort of biological marker, because what matters is a child's distress. And so if a child is feeling distracted and they're upset about it, that's real. That is our job, as the adults in their lives, to help them deal with that. And again, maybe medication is the right way to do it. Maybe not, but it's a very different situation than they need glasses, and so they're gonna get glasses. And so, yeah, I think sometimes the research about biomarkers and genes can get really complicated, but I think what is important to take away from it is that looking at ADHD as simply a biological disorder is not not right and not the most effective and helpful way for families to look at it instead, the way that a lot of the researchers who I spoke to looked at it is that it's about a mismatch between a child's specific 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 more complicated question. Sometimes, again, medication is the best way to do it, but sometimes there are things that can be changed in that child's environment that can improve how they're feeling, improve their symptoms without any kind of medication. I love that you describe the mismatch between the brain and the environment. I think that is absolutely true in my experience. I'm thinking of examples of my own family. My sister was diagnosed with ADHD. She struggled in school paying attention, but now she works in sales. She does not have to sit and listen to lectures. She's out and about meeting people, and she really thrives in that environment. And then I think about my first cousin, he also was diagnosed with ADHD. He could not sit still in school. It was really hard for him and his family. He was put on a stimulant medication. And now fast forward 25 years. He's a really successful fireman. He was just promoted to be a captain. He thrives in that environment. Environment. He loves what he does. He is so successful as a fireman, and to me, that's a very clear example of a mismatch between where he was struggling and an environment where he can actually thrive. So I think it's very true that a lot of stress that a person with difficulty with focus and inattention may have may be better served if they changed their environment? Yeah, and those are fascinating stories, and I think they really hit home, and there's research that backs that up, the MTA study, which I wrote about in this article, a fascinating and important study that followed a group of children with ADHD symptoms for more than 20 years into young adulthood. It found lots of important conclusions about ADHD and medication, but one of the ones that I find most interesting was this study that was done when the subjects were in young adulthood, like in college and just out of college, and so many of them had found a niche for themselves, whether it was in school or out of school, a new job, a major a way of living that was a better fit for their brains, and suddenly a lot of 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 can get to adulthood or adolescence and find a niche where they really fit. One thing I hear from a lot of families is that if you're in third grade and the environment where you're having trouble fitting in is a third grade classroom, the option to become a firefighter is not there for you right now, and so in that situation, sometimes, yeah, the right thing to do is to look for medication or some other more immediate treatment. Just the fact that things are going to get better in the future doesn't necessarily help when you're sitting there in that third grade classroom. But I think it's still a really useful idea for families to hold onto that this is not just permanent biological deficit. This is about a mismatch. I think that's really helpful to know, yes, just the idea that just because they have initiated a medication today, and then it's useful for their child today. It does not mean that they're going to be on this medication for a lifetime, by the way. Speaking of a third grade classroom environment, have you ever heard of give or Tully? By any chance I haven't. No Tell me about you might find him fascinating. I find him fascinating. He started a school in San Francisco. It's a Tinkering School, and it's designed for kids who struggle in the classroom. And he takes them outdoors, and he has them build things. And it's so fascinating, if you look at his website, anything that they want to create, he lets them create it. Oftentimes it's outdoors, and there is even a child who made 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 hard to scale throughout the country, I do find it interesting that he's thought outside the box to help kids that have difficulty in school thrive. Yeah, I think that's really useful. Both of my sons have gone to tinkering classes, not as thorough going as the school you're mentioning in San Francisco, but my sons love them, and I think lots of kids do, and I think especially kids for whom sitting in a desk all day, doing paperwork is not an ideal setting, which I think is most kids. The idea of making school more active, more engaged, more project based, I think that's good for everybody, but I think especially for kids who have a limited tolerance for boring stuff, I think that it's a great solution. Now I want to bring us back to talking about the MTA trial, because I find the results in this trial fascinating, and I know that in over the years, this has been cited as one of the most useful, well done ADHD trials. Can you explain what the trial was and what the ultimate findings were. Yeah, so this was a study that was started in the early 1990s at a moment where, as we were talking about ADHD, diagnoses were on the rise and Ritalin was the most commonly prescribed medication, and there wasn't a clear answer in the field as to whether Ritalin was actually the best treatment for ADHD, or whether there were behavioral treatments or a combination that would work best, and a group of scientists from around North America created this study in six sites where they recruited young people, I think, 789, year olds with ADHD symptoms, and They divided them into different categories. Some would receive medication, some would receive behavioral treatments, some would receive both, and some would just be left on their own to come up with the right solution for themselves. They found two things. First of all, after 14 months, they found that Ritalin was the most effective treatment for dealing with ADHD symptoms. But then, after the randomized controlled trial was over, they continued to follow these subjects in a long term study, and they noticed that the relative effectiveness of Ritalin was diminishing as the months went on, and by three years, by 36 months, there was no difference. On average. Urgent children who were in each of these categories and so continuing to make medication it looked like did not actually make a difference. They've now continued to follow these kids, as I was saying before, through young adulthood, and they continue to find that the ones who have stayed on medication consistently for all of those years, they don't show any fewer ADHD symptoms than those who never started medication or who started and stopped. And so there's a lot of debate about exactly what those results mean, but what a lot of scientists who were involved in the study believe is that ADHD stimulant treatments, Ritalin, Adderall, et cetera, they're effective in the short term, but less effective in the long term. And I think every individual's results might be different, but I think it's a really important idea for families to know about, because it goes against the sort of glasses analogy, right? Glasses continue to be useful for your entire life. Maybe you need to increase your prescription, but they remain useful, but ADHD medications are different, and that's I think, because ADHD is different than myopia, and it's really useful to know that fact, as you're trying to find the right treatment for yourself or for your kids. I mean, I find this really interesting, because from this MTA trial, I believe the American Academy of Pediatrics has recommended that the first line treatment for kids with an ADHD diagnosis, should be starting a stimulant. But I think it's a really important conversation piece to bring up when we talk to families about initiating medication, is this very fact that, yes, we may notice a difference initially, but over time that effect wears off. When I talk about this with friends, with family, they think, how can this make sense? As you pointed out, because they seem to work so well. But I also think that when people have an ADHD diagnosis, one explanation may also be that they find ways to work around how they learn. They may learn better and catch up in different ways. Maybe instead of sitting down and reading, they learn to be auditory listeners, or they find that they can learn by moving and by walking, people compensate for their difficulties in other ways that we may not recognize. Yeah, I think that's absolutely true, and I think the MTA study is fascinating for lots of reasons beyond that, they were relatively effective at 14 months and not relatively effective at 36 months. One of the things that's fascinating about it is that when you look at the data, it wasn't that the kids who had improved at 14 months suddenly got a whole lot worse at 36 months. It was that everybody got a little bit better. And that suggests something, right? It suggests that ADHD symptoms, often as kids get older, diminish. And other studies that the MTA scientists have done with that same group of subjects have showed that, in fact, there are all sorts of fluctuations that happen with symptoms over the course of childhood. It's not the case that everyone's just go away, but it is the case that they go up and down a lot, sometimes in unpredictable ways, through childhood, through adolescence and into adulthood. One fact that from one of these studies that I found really significant is that only about 11% one in nine kids who have the symptoms at seven or eight or nine persistently hit the clinical threshold of symptoms all the way through childhood and adolescence. Everybody else, almost 90% their symptoms go below that threshold for a certain period. Sometimes they go away altogether, sometimes they go away and come back and so that doesn't just mean don't worry about ADHD. It'll just go away on its own, but it does mean that again, this glasses analogy is not a helpful one. That doesn't happen when you need glasses. It's not like for a couple of years, your eyes suddenly get better. I also find that a lot of parents either they don't want their kids on a medication or they start their kids on a medication they don't like the effects. I think that the results of this trial give validity to the idea that it is a choice, that you can take a stimulant medication, but you also can approach the diagnosis with Nuance. Yeah, absolutely. One idea that I have found really meaningful is this idea that I think comes out of this new thinking about diagnosis in general, that a diagnosis, I think some of us have a tendency to want to cling really tightly to a diagnosis, to have it be the explanatory force in our whole lives, and that I think it's much more practically helpful and maybe psychologically helpful to hang on to diagnoses, psychological diagnoses lightly, right? This is one idea that might tell me something about what is going on in my life right now, or my child's life right now, but it's not going to be the explanatory force in their whole life. Maybe this is something that is true now and won't be true in the future. Maybe it's going to go away altogether. Maybe it's going to get worse, but it's not something to hang on too tightly. And when you do that, I think it opens you up to really following the evidence in your child's life, right? Maybe these symptoms aren't so bad, and they were bad a little while ago. We should try going off the medication, as you were saying, like maybe you don't need this medication on the weekend or over the summer. All of that, I think, just not only leads to better practical outcomes, but it also helps families think about. This diagnosis in a much healthier way, that this isn't something that's like a permanent deficit, a permanent disorder that's wrong with your kid. It is a situation that is serious, but that is about right now, and if we don't hang on to it too tightly, things might change. Things might get better. That's a really positive message, I think, as well as a very realistic one to give to kids and to give to families. Absolutely the message that we evolve, things aren't forever, things aren't permanent, I think, is a very helpful message, because, to your point, earlier, labels have their use. It can be helpful. It can make kids feel understood. It can make parents feel like their child is more understood, like they have a direction and a path forward. But at the same time. Sometimes I find that labels can be limiting. I think the title of my podcast, your child is normal, stems from that idea that sometimes these behaviors that we're so quick to want to diagnose, to want to treat, oftentimes, these are just normal childhood behaviors. And kids aren't easy all the time. They're difficult to raise. They can be feral. They can be wild, and I think sometimes it's just normal. Yeah, I think that's really true. And there's, I think that's true on an anecdotal level, like that I see in the kids around me, I'm sure in the many more kids every day and every week. But there's also research that suggests that, I think there was this idea a few years ago, especially, that giving a kid a biologically based diagnosis and saying you've got this biological disorder in your brain that would diminish stigma, that would tell them it wasn't their fault, it was just this thing that was broken in their brain. But there are lots of studies that say the opposite, and those make a lot of sense to me, that telling a kid there is something broken in your brain does not help them feel better about themselves and about their potential and their future, and then instead telling them what I think is this much more realistic story about ADHD as a problem they've got right now that might have to do with a mismatch that is part of something that we're all we all experience to a certain degree, some worse and more than others, and that might go away in the future that is just gonna lead to a more psychologically healthy outcome for them, they're not going to feel like this is the thing that defines me, this is the thing that makes me different from everybody else. They're going to think this is a problem I've got to take seriously right now, but it's not who I am. So I want to ask you more about medications and how they're thought to work, and the potential side effects that may come from the medications. So my first question, why do we think stimulants work in the first place? They do tough? Said, so, you know, these stimulants are all based in amphetamines, and we have known now for almost 100 years in this country that amphetamines are a really powerful drug, and they have good effects, and they can have some bad effects as well. And they kind of do that with everybody. I think there's this idea that some people in the ADHD world believe it, that these medications are only effective on people who have an ADHD diagnosis. But that's not the case. There are lots of studies that show anyone who takes these medications or amphetamines in any way, they have some version of the same response, which is, they can focus more. They don't care about distractions. They have a much higher tolerance for boring stuff. The Times, historically, when we've used it have been like with people who are doing incredibly boring jobs, soldiers who have to stay up all night just staring at the sky, watching for planes, long haul truck drivers, these are all people for whom amphetamines have been really useful because they let you focus on things that are kind of boring. High Schools, for instance, is also kind of boring, and so it makes sense that these medications would help kids focus, but there have always been downsides to amphetamines, and I should clarify that the medications that we're giving kids now have a lot of safety features that make them less prone to abuse than amphetamine medications in the past, but it's still the same basic drug, and it's always had downsides. So a lot of the young people who I spoke to said they felt like it changed their personality, they were less social, they were less able to engage. All of which makes sense, right? If you're only focused on the one thing in front of you, you're not as funny, you're not as fun, you're not as spontaneous. And so I think a lot of families, a lot of kids, say they don't like the effects, and a lot of them stop taking it over time. But in the short term, in terms of managing those symptoms, diminishing that distractibility, letting you focus on the stuff you're supposed to focus on, on average, they're really effective with lots of people, but it does not make you smarter, correct, it does not change your IQ. So in essence, what you're saying is the medications work by helping you focus on boring tasks. They make boring tasks less boring, and you're able to sit and focus and focus and do things that you might not want to do, or a less preferred task. That's right. Sometimes among college students, anyway, they 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 in controlled situations, when scientists divide kids up into those who receive the medication. And those who don't, the ones who receive the medication, do behave better. They act out less, they focus on their work more. But when you test them on how much they've learned or how able they are to answer complicated questions, there is no real difference between the kids who receive the medication and who don't, and we're not entirely sure why that is, but the theory that makes a lot of sense to me is to think that we should be thinking about these stimulant medications as working on our emotions and our motivation more than on our cognition. It changes the way you feel about the work that you're doing. And that's not nothing. Emotion is certainly important, and it's a big deal for every kid, but it's really valuable, I think, to understand that's what's happening. What we're doing is not making ourselves smarter, not making ourselves better able to do these tasks, it's changing the way we feel about the work we're doing. Sometimes temporarily, I find that a lot of parents worry that their kids are more likely to be to be addicted to these medications over time, that it might be a gateway drug to more drugs in the future. So I appreciate that you mentioned that these drugs are formulated to keep kids from growing an addiction to the stimulant medications. But there are some real side effects, and you touch upon a lot of them in your article. Can you mention some of the real side effects that you noticed that might surprise people listening? Well, the side effect that the MTA study pointed out, which I think is a surprise to a lot of families, is about height suppression. And again, there's debate in the scientific community about how consistent this result is, but in the MTA study, at least children who consistently took stimulant medication over time were about an inch shorter than their peers who didn't take those medications. And initially, the researchers thought that this was just a short term, temporary difference in height and that it was going to change as kids hit puberty. But it doesn't, according to the MTA, and when they now look at the adults, the ones who have consistently taken medication are still an inch shorter than their peers. There are lots of people who say that is a small price to pay for the benefits of medication, but it is absolutely something I think that kids and families should be aware of, and I think it's another reason to think about stimulant medication, not necessarily as a long term solution, but as a short term solution, as something to try for a while to get through a crisis period, but it's, on average, at least a significant effect, according to the MTA of long term stimulant use. Yes, and to your point, I think that takes me back to the idea of making it a shared decision that you want parents to understand the full potential benefits and the full potential negatives. As you pointed out, an inch may not be much to somebody who's struggling with behavioral issues with their child, and they feel like the stimulant makes a big difference in their quality of life, in the life of their child and the life of their family. But for some families, that's important, and I think that's really interesting to point out, I agree. I also find too it's stressful for families that kids have a diminished appetite that causes a lot of stress. For a lot of kids, when the medication wears off, they seem more irritable. So they may get the benefit of a focused child for a few hours, but then as the medication wears off, that can also be stressful for families, some kids suffer from insomnia, so I find that they may be on a stimulant during the day, but then they end up needing another medication or something else to help them sleep at night. And for kids that have tics, once they're started on a stimulant medication, those tics may exacerbate so there are a lot of side effects to these medications that I think it's worth bringing to light, just so that parents can take all these factors into consideration. Yeah, I think it's a serious medication for sure, and it doesn't simply make it easier to pay attention and not have any other effects. I felt I learned a lot from talking to the young people, mostly adolescents, who had taken the medication. And some of them were more positive about the experience than others, but all of them saw it as a series of trade offs. The one word a few of them used was a sacrifice. This is not something I like doing, but I see it as a sacrifice that I have to make for the future. And the adolescents themselves have these very nuanced approaches, like I take it on certain days when I need to feel one way or need to do certain tasks and not on other days. There was one girl I spoke to who it was like the end of summer, and she was about to say goodbye to her friends who were all going back to college, and she said she didn't take it that day so that she could have the more deep sort of emotional connection with sadness of her friends going away, because she knew that if she was on the medication that day, there would be something diminished about her emotional responses. So I think really listening to kids, especially adolescents, as they get more expressive about what their experience is with that medication, how it makes them feel in different situations, that's really important. And I think there's sometimes a pressure on families that the only conversation should be like the adults telling the kids to take these medications and make sure you do it on time. And I think when you can have a real conversation about what the pluses and what the minuses are of taking the medication, you. It's going to be a much more successful experience. So this is really helpful, and I want to talk now beyond medications. In your article, you highlighted how changing a child's environment may ease symptoms. Can you give an example of what that might look like? I want to make sure families understand the other options that are out there beyond medication. So there are lots of behavioral interventions, some whole programs that have particular names and some that are just more ad hoc. My understanding is that there isn't one that, through a rigorous test, been proven to be more effective than medication over the long haul. But I don't think that means that environmental changes can't be very effective. I just think they have to be more individualized and spontaneous and reflective of the individual child. Changing the dynamic at home can often make a big difference when kids feel more accepted and understood, when they feel like their distractibility or their problems staying focused are something that they can work on, sometimes with little fixes like post it notes and lists on the wall and schedules and that this is something that they can get better at with help and with effort. I think that's can often lead to really positive changes. And similarly, at school, there are ways that assignments can be more or less distracting when changes can happen in the way that a classroom is set up where you do homework, when that can change, sometimes in small ways, it can really help. I don't think there's a magic bullet where we can say this is the behavioral intervention that's always work, but I do think that changing environments can help. Yes, I especially find that for the young boy, 789, 10 years old, who's got a lot of energy and can't sit still in the classroom. I'll often advise parents to talk to teachers about making sure they have their recess, making sure they move their bodies, maybe doing jumping jacks in the middle of class, taking 10 minutes before school starts to run sprints, similar to having a puppy. You gotta get their energy out or they're not gonna sit still. Totally Yeah, I think that's absolutely right. And I think again, it comes down to communication and understanding between the child, parents and ideally, a teacher in a school, and that when all of those three individuals are able to work together and to see this as a problem that is real, but that is solvable. You can often come up with some really creative solutions. And I think that idea of thinking of it as a solvable problem is psychologically really positive for the kids, because they don't think, Oh, this is my problem. This is a disorder that I've got that means I'm different, that means I'm weird, that means I'm broken. Instead, they're like, this is something that we can solve and that we're all going to solve together. Absolutely I do feel like this is a group effort. I find a lot of parents come to me either stressed because they feel like the teacher is asking for the parent to come to me to request medication, or I find often that parents are relieved that their teacher understands that the child is having difficulty, works to make accommodations for that particular child. Maybe they're an experienced teacher, or they've had a child themselves that struggled, and that is so relieving for families when they feel like their child is understood for sure. So as we wrap up, if you could change one thing about the way we talk about ADHD, what do you want parents to better understand? I think it's really useful for parents to understand that an ADHD diagnosis is not a sort of permanent and essential thing about a child, that it does not indicate that this child has a brain defect that is permanent and is never going to change, never going to go away. And I think that's important for a couple of reasons. I think it's important because it's true, because I think all the evidence is there that we can't say that for sure about ADHD, I think it's important because on a practical level, it's going to lead to better solutions. It's going to push parents, I think, to find solutions and to work with their kids and their pediatricians and their kids teachers to find good solutions. And I think it's also really important psychologically, that it gives the message to children who I think are really the ones we need to care about the most in this dynamic, that they are not broken, that they don't have this deficit that is never going to go away, that they have a serious situation that they need to take seriously with their family's help and with their school's help and with their pediatricians help. This is not the thing that's going to be the most important fact in their lives. This is going to be one thing that is worth dealing with and worth thinking about, but it's not going to be the thing that defines the rest of their lives. And if people want to read more about what you do, where can they find you? I have a website at Paul tough.com that has links to my stories and my books, so that's a good place to start. Paul Tough, thank you so much for the research that you do, and I really appreciate you taking the time to come on your child as normal. Thank you so much. Thanks for inviting me on. Thank you. So much. Thanks. Thank you so much for listening to my conversation with Paul Tough and for joining me for the special 200th episode. And if you enjoyed today's episode, it would mean the world to me if you could do two things, share this episode with a friend or another parent who might find it helpful, and leave a five star review wherever it is. You listen to podcasts, it really helps other parents find the show and join this community. See you next Monday. You.