The below is based on an article by Paul Tough. It was published on April 13, 2025 in the New York Times Magazine.
Attention Deficit Hyperactivity Disorder (A.D.H.D.) diagnoses are at an all-time high, with 11.4% of American children—7 million kids—carrying the label in 2023, a sharp rise from 2 million in the 1990s. Alongside this surge, prescriptions for stimulant medications like Ritalin and Adderall have skyrocketed, increasing 58% from 2012 to 2022. But as the numbers climb, a growing chorus of experts is questioning whether we’ve been approaching A.D.H.D. correctly, challenging the assumption that it’s a purely biological disorder requiring a medical fix.
The Rise of A.D.H.D. and the M.T.A. Study
In the early 1990s, James Swanson, a research psychologist at UC Irvine, found himself at the center of a contentious debate. The Church of Scientology was protesting Ritalin, the go-to A.D.H.D. medication, accusing psychiatry of “drugging kids.” At the time, A.D.H.D. diagnoses doubled from under a million in 1990 to over two million by 1993, with most children prescribed Ritalin. Swanson, believing 3% of kids had A.D.H.D., saw this as appropriate.
To address questions about Ritalin’s efficacy, Swanson led the Multimodal Treatment of Attention Deficit Hyperactivity Disorder (M.T.A.) study, a landmark trial comparing stimulants, behavioral therapy, and combined approaches. Initial results in 1999 showed Ritalin significantly reduced symptoms after 14 months compared to behavioral therapy alone, cementing its use. However, by 36 months, all groups—including those without treatment—had similar symptom levels, revealing no long-term behavioral benefits. Worse, children on Ritalin grew about an inch shorter on average, a gap that persisted into adulthood.
Swanson, now 80, is troubled by these findings and the A.D.H.D. field’s direction. “There are things about the way we do this work that just are definitely wrong,” he says.
Challenging the Medical Model
The traditional view of A.D.H.D. as a fixed, brain-based disorder—often compared to “diabetes of the brain”—is losing ground. Edmund Sonuga-Barke, a researcher at King’s College London, notes a disconnect: “We have a clinical definition of A.D.H.D. that is increasingly unanchored from what we’re finding in our science.” Despite decades of searching, no reliable biological marker (like a brain scan or genetic test) confirms A.D.H.D. as a distinct condition. The 2017 Enigma Consortium study, for instance, found negligible brain differences in A.D.H.D. patients, undermining claims of a clear neurological basis.
Sonuga-Barke argues A.D.H.D. symptoms exist on a continuum, not as a binary “you have it or you don’t” condition. Environmental factors—like trauma, anxiety, or an unsuitable setting—can mimic or exacerbate symptoms, complicating diagnosis. Over 75% of kids with A.D.H.D. have another mental health condition, such as anxiety or a learning disorder, blurring the lines further.
Medication’s Limits
Stimulants like Ritalin and Adderall, rooted in a 1937 discovery by psychiatrist Charles Bradley, remain the standard treatment. They often produce striking short-term behavioral improvements, described by researcher F. Xavier Castellanos as “almost mystical.” Yet, studies consistently show they don’t enhance academic performance. A 2023 study by Elizabeth Bowman found adults on stimulants worked harder on cognitive tasks but performed no better than those on placebos. A 2022 study by William Pelham Jr. showed similar results in children: better behavior, but no learning gains.
Why do families still rely on these drugs? Research by Martha Farah suggests stimulants boost confidence and motivation, making boring tasks feel engaging. As sociologist Scott Vrecko found, students describe falling “in love” with their work on Adderall, not because it sharpens their intellect but because it makes tedious tasks tolerable—a phenomenon historically seen in soldiers, housewives, and truckers using amphetamines to endure monotony.
But the downsides are significant. Beyond growth suppression, stimulants carry risks of addiction and, per a 2024 study, tripled odds of psychosis or mania at medium doses. Many teens, like “Cap” and “John,” dislike the emotional flattening or appetite loss, often stopping medication outside school. Cap used Ritalin situationally for SAT prep and baseball, while John felt “completely regular” without Adderall in summer, highlighting A.D.H.D.’s context-driven nature.
A New Perspective: Environment Matters
Recent M.T.A. studies reveal A.D.H.D. symptoms fluctuate over time, with only 11% of diagnosed kids showing consistent symptoms year after year. Margaret Sibley notes that 40% of non-A.D.H.D. kids in the study later met diagnostic criteria, suggesting environmental changes—like a demanding school—can trigger symptoms. A.D.H.D., it seems, isn’t always a fixed disorder but a condition shaped by context.
In 2016, M.T.A. researchers interviewed young adults who had A.D.H.D. as kids. Many reported their symptoms vanished after finding a “niche”—a career or study path aligning with their interests, like film, hairstyling, or auto repair. These environments, whether cognitively demanding or hands-on, felt “intrinsically interesting,” reducing distraction. Sibley found symptoms often improved during high-demand periods, challenging the idea that A.D.H.D. worsens under pressure.
Sonuga-Barke proposes a new model: A.D.H.D. symptoms signal a mismatch between a person’s biology and environment, not a brain defect. He advocates building supportive settings—like engaging schools or jobs—over relying solely on medication. This approach, he argues, improves mental health and self-esteem, reducing the stigma of being “defective.”
The Stigma of Diagnosis
Labeling A.D.H.D. a “brain disorder” can backfire. While some families find a diagnosis empowering, Luise Kazda’s 2021 review found it often increases shame and isolation, fostering an identity tied to prejudice. Sonuga-Barke’s model, by contrast, frames A.D.H.D. as a trait on a spectrum, encouraging families to explore environmental tweaks—like a new school—or address co-occurring issues like anxiety, alongside medication if needed.
A Path Forward
Rethinking A.D.H.D. as a contextual condition requires flexibility from families and doctors, but it offers hope. It aligns with science showing symptoms aren’t fixed and empowers kids to see themselves as “different, not defective.” For some, medication may help navigate tough environments; for others, finding the right niche could be transformative. As Sonuga-Barke reflects from his own A.D.H.D. journey—thriving in college after struggling in school—the key is creating a world that fits the unique wiring of each mind.
Paul Tough is a contributing writer for The New York Times Magazine, focusing on education and child development for over two decades.
