Title: A History of ADHD and its Treatment

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Brian Lehrer: It's The Brian Lehrer Show on WNYC. Good morning again, everyone. Now we'll take an in-depth look at a psychiatric diagnosis that you might say has taken America by storm. Attention deficit hyperactivity disorder, commonly known by its initials, ADHD. While it used to be considered a rare childhood disorder affecting just 3% of the population, the CDC now estimates 15 million adults are living with adult ADHD in the United States as of last year.

What's behind the boom in ADHD diagnoses, and what even is this disorder that it seems like half the people you know might have? In the latest season of the podcast Backfired, hosts Leon Neyfakh and Arielle Pardes tackle these questions and more. Take a listen to the trailer.

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Leon Neyfakh: I'm Leon Neyfakh.

Arielle Pardes: I'm Arielle Pardes.

Leon Neyfakh: This is Backfired, Attention Deficit. In this season of Backfired, we're telling the story of how ADHD became the defining diagnosis of our time, and how the drugs used to treat it have become part of daily life for millions.

Arielle Pardes: It's a story about the promise of psychiatry to fix our brains.

Speaker 4: I wonder if this is how everyone else feels.

Speaker 5: Do people just function without it being painful all the time?

Leon Neyfakh: It's about the power of the pharmaceutical industry to shape how we and our doctors think about what's wrong with us and what's going to make us better.

Speaker 6: Doctors in general want to help people, but on this, they were so sloppy.

Arielle Pardes: It's also a story about what it means to be normal.

Leon Neyfakh: Who gets to decide when someone isn't.

Speaker 7: They want to have little zombies sitting row on row in the classroom.

Speaker 8: There is always some legal case going on.

Speaker 9: I say we get rid of Ritalin. We don't like it. We don't want it. Get rid of it.

Arielle Pardes: This is Backfired, a podcast about the business of unintended consequences. Season 2, Attention Deficit.

Brian Lehrer: Joining me now to discuss their findings and to take your stories and comments and questions are Leon Neyfakh and Arielle Pardes, hosts of Backfired, Season 2, Attention Deficit. Thanks for joining us, WNYC.

Leon Neyfakh: Thanks for having us.

Arielle Pardes: Thank you. Good morning.

Brian Lehrer: We heard the trailer. Let me dive right in with a clip from the podcast itself. Arielle, we'll hear you asking what seems like a simple question to your interviewees. This is a one-minute clip.

Arielle Pardes: This is a question we're asking every single person we interview for this season. The question is, what is ADHD and how do you know if someone has it?

Speaker 10: Oh, golly.

Arielle Pardes: Oh, no.

Speaker 11: That's a loaded question.

Speaker 10: ADHD is a health condition, that leads to kids having some symptoms that interfere with their ability to do the kinds of things they're supposed to do.

Speaker 11: How do I answer that? I don't even know how to answer that, really. What is it? ADHD is a diagnosis that you'll find in the diagnostic and statistical manual of mental disorders.

Brian Lehrer: Now that we've heard all that hesitation and hemming and hawing, Arielle, I'll turn the question you were asking over to you to try to answer. What is ADHD? How do you know if someone has it? I'll add, why do you think everyone you interviewed struggled to give you a satisfying answer?

Arielle Pardes: This is the million-dollar question, Brian, and I think this is really where we started our reporting was this paradox that it seems like everyone is talking about ADHD. It's all over TikTok. It's all over the news. So many people that we know have it and have been diagnosed recently, but at the same time, experts really struggle to pinpoint what exactly it is. That's because, like so many psychiatric disorders, ADHD is subjective.

The definition which has been in the DSM since the 1980s includes symptoms like being forgetful or being restless or fidgeting, which are things that I think everybody experiences to some degree. The question of ADHD isn't so much, "Are you experiencing those things? Are you distracted? Do you have trouble paying attention?" It's, "To what degree do you experience those things, that it becomes a disorder?"

I think this whole season of Backfired is really about people finding that line and really fighting to change where that line is. In other words, fighting to define what constitutes normal behavior and what constitutes a psychiatric disorder.

Brian Lehrer: Leon, you want to pick it up from there and say why people would be fighting to redefine what ADHD is, where that line between so-called normal and so-called psychiatric disorder is? Who's being disadvantaged by the current either confusion or definition?

Leon Neyfakh: As Arielle said, ADHD made it into the DSM in the '80s, but two decades before that, there was an understanding that certain kids had trouble focusing at school. They had trouble paying attention. They had behavioral issues. It was understood to be, as you said, Brian, a very rare disorder. It was estimated to affect about 2% to 3% of the child population in America when it was first described, and as a result, it was, I think, very deeply stigmatized.

I remember growing up in the '90s, and even then, the kids in my class who had ADD were seen as weird. They were seen as dysfunctional. I thought of them as troubled. I think a big part of the discourse around ADHD over the past 40, 50 years has been about lifting some of that stigma. There are patient advocates and family advocates who have fought really hard to make it so that people who suffer from this disorder can function to the full extent of their abilities and to reach their potential.

I think that has driven greater awareness of the possibility that someone who is having trouble at school might actually have this condition and might need treatment for it in the form of drugs. I think what we've seen over the last maybe 10 to 20 years is a melting away of that stigma, to the point where now, as we're just saying, it really feels like you look around and everyone suddenly has this. Half my friends seem to have Adderall or Vyvanse prescriptions.

I think part of what we tried to do with the show is ask, "Did we go too far in destigmatizing this disorder to the point where it backfired?"

Brian Lehrer: Listeners, who has an experience with or a question about ADHD for our guests from the podcast Backfired, which they call a podcast about the business of unintended consequences? You could hear Leon and Arielle laying out some of the unintended consequences just now. Season 2 of Backfire, Attention Deficit. Who has a question or an experience or a comment you want to share? 212-433 WNYC, 212-433-9692.

Call or text and help them report this story. Help everybody listening who has or knows someone with a relevant prescription or a relevant diagnosis, or who thinks maybe they should have one or shouldn't have one grapple with their lives. 212-433 WNYC, call or text. 212-433-9692. Arielle, let me pick up on what Leon was just saying about the treatments. When we think of treatment for any sort of disorder or illness, typically the illness is identified before the drugs are manufactured, but in your podcast, you note that stimulant medications, particularly Ritalin, were like a treatment without an illness.

How did we notice, we as a society, that Ritalin could be used to tame so-called hyperactive children, and what were the controversies surrounding this discovery early on?

Arielle Pardes: It's a great question. As you said, back in the 1950s, amphetamines, and methylphenidate, which is the drug that is now called Ritalin, these were very effective at a lot of different things. They were helpful for focusing people. They were helpful for clearing nasal congestion. They were believed to possibly be antidepressants. The story of how these became treatments for ADHD really goes back to some very early researchers who were working with primarily boys in troubled group homes or foster homes, who discovered that giving methylphenidate or amphetamine to these kids really reduced their symptoms of behavioral disorders.

This was like an aha moment that led to a lot of other research in the '50s and '60s that was really considered miraculous. These were kids for whom nobody really understood what to do with. They were just considered troubled and a nuisance. They couldn't really get on in school or even at home, and it seemed a breakthrough that you could give them one of these pills a couple of times a day and they would just behave. In a sense, the medication is miraculous.

ADHD is considered one of the most treatable psychiatric disorders, which is something that's, I think, really important to note that if you do have these problems, there's a very easy solution to fixing it. I think the controversy comes from understanding in what cases people "really need the drugs," and in what cases people just enjoy the effects that they produce. Just as soon as this discovery was made back in the '60s, there was national controversy over whether this constituted a legitimate medical treatment or whether it was something more akin to drugging children to make them more palatable to adults. That controversy has just repeated over and over every decade since.

Brian Lehrer: We're going to play another clip from the podcast. Then we're going to go to some of our many calls. You can imagine how many people are calling in when we raised this topic in the way that you have. You spoke with Ross Young, whose family ended up moving across state lines due to the pressure that school administrators put on his family to medicate their children. Here's a clip of how he now remembers school back then.

Arielle Pardes: Ross had trouble paying attention in class and finishing his homework. He remembers not being allowed to go to recess. He didn't know why exactly, but he got the impression it was because of his bad grades.

Ross Young: I can remember vividly the kids going out for recess, and I can remember times when they'd turn the light out and I'd be the only one in the room, and everyone would be gone, including the teacher. I'd get up and I'd walk over to the window, and I'd look at the kids having fun. I do not remember ever going out to play. I do not remember that at all.

Brian Lehrer: Leon, listening to that clip, the stigma surrounding the disorder really comes through. How do you look in the podcast to balance taming the stigma with helping kids who may actually be suffering from some version of something called ADHD?

Leon Neyfakh: I think what people worry about, as Arielle was saying, is that while there are undoubtedly people who experience these symptoms to such a degree that they can't live normal lives and that they encounter draconian restrictions at school, we're talking about the '60s here, Ross Young, who you just heard, he also talked about having a partition set up on his desk so that he wouldn't be distracted by the other kids while he was supposed to be paying attention to the teacher.

It makes you really sad to hear it. The idea that there is a pill that you can take that makes all of that unnecessary, and that makes it possible for teachers not to resort to such traumatizing, I would say, measures was treated, as Arielle said, as a miracle. I think in terms of balancing that against the risks of putting too many kids on these drugs, for me, I've always thought of these drugs, speaking as someone who abused them in college, and I talked about that on the show, they really change you in certain ways.

Of course, they affect different people in different ways. I have friends who are on massive doses of stimulants who need them to drive, who need them to get out of the house in the morning, and who need them to stay on task at work, but at the same time, there are people like me as a college student, for whom, really, they warp you. They warp your sense of self, they warp your consciousness. They create dependence.

I think what we see as we track the rising, exploding rates of diagnosis and prescriptions over the decades is the possibility that we are giving these drugs to people who "don't need them" but who are also changed in ways that maybe we should be worried about.

Brian Lehrer: We may have a caller very relevant to what you were just saying and what was in the clip. We certainly can add this question to the invitation for you to call in the way I gave it before. Can you relate listeners to that clip we just played of Ross Young? Were you excluded from recess or made to sit away from your peers in class due to your hyperactivity? What was it like growing up with ADHD? Were you pressured into taking medications as a child or anything related? Kyle in Brooklyn, you're on WNYC. Hi, Kyle. Thanks for calling in.

Kyle: Hey, Brian. You can hear me, right?

Brian Lehrer: Yes. We got you.

Kyle: I obviously had difficulty in school. My mom was like, "What can we do about this whatever?" She heard about this doctor, and so we went. I remember being in the waiting room, and we saw a lot of kids there. I went in and he just talked to my mom. They looked at my grades, and then he looked at me, didn't ask me very many questions. I walked out of there, I was taking Adderall at a low dose. A couple of years later, I was taking Vyvanse about 50 milligrams.

This is by the time I was getting into high school. That's how high up it was. I was never really asked, "Why is it hard to concentrate in school or whatever?" The reality is that these school boards, it's too much money, too much work to make a curriculum interesting and engaging. You have a couple of kids or a bunch of kids that don't want to pay attention so they just, "Let's just medicate them all." I don't think that's a good solution.

When I started to talk to psychologists and psychiatrists, I found coping mechanisms and ways to get around some of my issues that didn't mean that I had to take pills every day, and I don't take pills anymore for this.

Brian Lehrer: That's a great story, Kyle. Arielle, I wonder if it comes up in the podcast. People who were diagnosed with ADHD as kids, put on medication, and then found ways through therapy, in Kyle's case, maybe through other ways to get off it as an adult.

Arielle Pardes: Yes, absolutely. I think, Kyle, what your story reminds me of is just how much medication was pushed as the only solution to treat ADHD for many, many decades. In the 1990s, there was a major longitudinal study that seemed to confirm that medication was the best treatment for ADHD. The media had a field day with that, and that study later got debunked. It was proven that actually behavioral therapy combined with medication worked much better than medication alone.

Many people did perfectly fine with behavioral interventions alone. I do think that over the decades, particularly in the '90s, when you had so many new pharmaceutical drugs coming on the market, including Adderall, you saw this huge push to just give the kids pills. I think what Kyle's story makes me think of is the fact that this is one of the only psychiatric disorders in which a diagnosis doesn't actually rely on the person experiencing the disorder.

It's very common with ADHD that it's diagnosed by interviews with parents, with teachers, with assessments in a community, but it's not always the case that the child is the one who says, "I'm really struggling and I really want to pursue this as a treatment." I think that's been one of the ongoing controversies is this idea that medication alone is a silver bullet, which isn't entirely true. It does help lots of people, but there are, of course, other options.

There are people that we talked to in the show who had this exact experience of being put on medication at an early age and then having an awakening in their adulthood about what these drugs were actually doing to them and the degree of choice that they wanted around managing their own behavior.

Brian Lehrer: We're talking listeners, if you're just joining us with Leon Neyfakh and Arielle Pardes on their new podcast series, the Season 2 series in the Backfired podcast called Attention Deficit. One of the premises from the podcast that we laid out at the top of the segment was that it's being diagnosed a lot more these days in adults when it used to be primarily kids. Let's take a call from somebody who has been diagnosed as an adult. Acacia in Brooklyn and Greenpoint, you're on WNYC. Hi, Acacia. Thanks so much for calling in.

Acacia: Hi. I was diagnosed at 33 and it was a long journey. When I was a kid, teachers had said, people had said to my mom, "I think maybe you should have her evaluated. Maybe she needs medication." My mom was very anti-medication. She was like, "She's great. She loves to read. She's very engaged," but I struggled. I would do my homework and I would just not turn it in. I thought my whole life I was lazy and depressed. I would sit there completely frozen with my head racing in thought.

I think one thing that's not talked about a lot is the difference in ADD in boys and girls. I wasn't necessarily hyperactive, but I was just very, very inattentive. Finally, I was at my doctor's office as an adult and was telling her about some stuff, and she's like, "Have you ever been diagnosed with ADD?" I was like, "No." She's like, "You should look into it." I looked into it. I got on medication, and it was absolutely life-changing.

Like you had said previously about driving, I thought I was afraid to drive my whole life. Again, I thought I was lazy and I couldn't do anything, and it changed my whole life and made me so much of a better mom, sorry, I'm getting emotional, and just a better person. It really, really did. The thing that really is hard is just managing my medication and being able to get it. Having ADD and having to make an appointment every month with my doctor to get my medication and doing that, that's really challenging. I wish there was a way to loosen that up, but it has absolutely, drastically changed my life for the better.`

Brian Lehrer: In a way, your story is the opposite of the first caller who was diagnosed and put on medication as a kid and found a way to fight his way off it as an adult, and was down on medication being used or overused. For you, you're so happy [crosstalk] that you discovered medication and what it could do for you with ADHD as an adult.

Acacia: Yes. I had done CBT, cognitive behavior therapy, and I had tried all these things. Then actually, once the medication was added to everything after, it was night and day. I spent so much time in therapy as a kid trying to get the routines down, and once I was an adult and got the medication, everything clicked into place.

Brian Lehrer: Thank you so much for sharing your story. I'm sure that's very helpful to people, too. Leon, so interesting that these equal and opposite callers are both legitimate parts of this complex picture, right?

Leon Neyfakh: Totally. We talked to people who are similar to both. There were so many people we spoke to who described the moment they got on medication as this eureka moment where they realized that all the problems that they had been struggling with for their whole lives had not been their fault in this way, that there was a solution. I think one thing that makes me think about as we look at the explosion and diagnosis and prescription is that no one serious disputes that there are people for whom these medications and these drugs are life-changing in a good way.

As we see the proportion of the population grow that takes them, that self-identifies as having ADHD or simply gets a prescription because the stimulants they get through it are helpful to them, make them more productive, make them need less sleep, essentially, people who take them as performance enhancers. The more people like that there are, and I would count myself in this population of people, who, as I said in college, took them to stay up later and do more homework, that has the effect of A, depleting the reserves of this medication that are available. We haven't talked about the shortage so far. [crosstalk]

Brian Lehrer: There's a current shortage.

Leon Neyfakh: That was a big impetus for us making this show is that there are simply not enough of these drugs to go around for various reasons, but the other component of that is, I think, rampant, let's call it over-diagnosis or rampant abuse by people who are simply taking these drugs as performance enhancers delegitimizes ADHD in the eyes of so many people who then look at someone like the caller who we just heard from, and they don't believe her.

That's not good for people who have this disorder either. This negotiation of the stigma is really a double-edged sword.

Brian Lehrer: We're talking with Leon and Arielle, the co-hosts of the podcast Backfired, which describes itself as a podcast about the business of unintended consequences. Their Season 2 now dropping called Attention Deficit. We'll take more of your calls and texts and keep exploring this territory right after this.

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Brian Lehrer on WNYC as we continue with the co-host of the Backfired podcast series Season 2, Attention Deficit. Leon Neyfakh and Arielle Pardes host the Backfired Season 2, Attention Deficit. Let's take another call. Here's Archer in Garrison, New York. Archer, you're on WNYC. Hello?

Archer: Hello, can you hear me?

Brian Lehrer: We can hear just fine. Thanks for calling.

Archer: Great. I am 55 years old. I'm that late baby boomers generation, and I have ADHD. I was diagnosed in my 40s. My parents sweated blood to clothe and to put us in private schools. It was not known then, or at least it wasn't recognized, and then in college to put us through. I was told I was lazy. Always very bright, but lazy, lazy, lazy. It really affected the way I was seen in my family, especially by my parents. I also have a reading disability.

I ended up going into theater rather than being a clinician, which is what I really wanted to do and am today. I went in a very circumscribed way until I was finally in my 40s, had enough confidence to go and get a social work degree at [inaudible 00:26:11] and become the somatic psychotherapist I wanted to be. Before that, I was an actor. The reason I'm going into this is because Gabor Maté writes a lot. Maybe your guests know.

Brian Lehrer: You're referring to Dr. Gabor Maté. Go ahead.

Archer: I am, sir. I am. Thank you. He wrote a book called Scattered in '98, and I think it was re-released in the early 2020s. He's an amazing clinician who writes beautifully about his own ADHD. The other thing that he talks about is that there's two kinds of ADHD that we're all struggling with.

One of them, according to a study by Greenberg & Greenberg, is sociological, and it has to do with the event of cyberspace in our lives and the fact that we're all competing with information flying so fast that there's almost a sociological ADHD. Then there are those of us that have it organically, often from a result of perinatal brain trauma, he talks about, and/or it's also often comorbid with major depressive disorder.

Then the last thing I want to say is that it's also been noted that it can come through families that have a history of alcoholism, transgenerational. I don't know if all that smorgasbord is of any help to anyone, but I would love to hear them address any or all of it.

Brian Lehrer: Thank you, Archer, for a very rich call. Maybe the thing to zero in on there, Arielle, is the distinction that she was referencing, and if this comes up in the podcast, or if you think it's real, between the neurological or organic or biological ADHD and what she called sociological ADHD, something that comes from the dominance of cyberspace in our lives and so many different little bits of information going by so fast.

Arielle Pardes: I love this distinction. It goes back to the question Brian, you asked at the top of the segment, which is, what is ADHD? There still is a degree of controversy or lack of consensus around whether it is something that exists in our brains, whether it is something that exists in our genes, or whether it's something that can perhaps also be produced by our environment. These questions are not completely agreed upon in the field of psychiatry, but they seemed very interesting to us as journalists.

I think when you talk about something like an environmental or sociological version of ADHD, it helps to explain why there's been this huge boom in the disorder in the last few years. Close to a million Americans have been diagnosed with ADHD for the first time in the last three years since the COVID pandemic. I think if you consider that, one psychiatrist put it to us as like, you almost have to be like an epidemiologist and say, "Why is this disorder spreading all of a sudden right now?"

One of the answers to that, that I think again is debated, but seems to make some kind of logical sense is that we live in a completely different environment in America in the last three years. We're living in information overload, distractions are high, social structures have dropped, and those things can all produce these symptoms of inability to focus, distractibility, fidgeting anxiety that all manifest as ADHD.

Brian Lehrer: I even remember Leon reading an article I don't remember by who or where, probably around the time that Dr. Maté's book came out that argued that ADHD, instead of being a disorder, might be looked at as an adaptation to the cyberspace, Internet-prevalent world we're living in and that people with a little bit of ADHD, mostly younger people, might have an advantage in competing in this world against older people or people who didn't have it, who might be overwhelmed and therefore not dealing as effectively with cyberspace.

I don't know that anybody argues that anymore, but that one stuck with me. I always remembered that argument. I wonder if it's something you came across.

Leon Neyfakh: We've certainly come across-- especially when we looked at TikTok communities of people who have ADHD and talk about ADHD to their followers, there, I think, is a growing-- I think this is part of the stigma conversation. There's a growing push to recharacterize ADHD as a superpower. Some people talk about it as something that gives you an advantage. For me, it doesn't intuitively make sense that having ADHD would make it easier to deal with the onslaught of media and distraction that we're all on the receiving end of these days.

I do think that the fact that so many people now are accustomed to spending six to 10 seconds inhaling a video and then moving on to the next one means that our attention spans are worse, by and large. I do think it's really easy to confuse that with the biological manifestation of ADHD.

Brian Lehrer: Let me jump in for time. You mentioned the TikTok phenomenon of people discussing their ADHD. Here's a 16-second montage from your podcast of newly diagnosed women sharing their diagnoses on TikTok. TikTok, this is from episode 10 of Backfired, Attention Deficit.

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Speaker 12: This is how I got diagnosed with ADHD at 30 years old.

Speaker 13: I'm 29 years old. I got diagnosed with ADHD five months ago. It has completely changed my life.

Speaker 14: This year, I got diagnosed with ADHD.

Speaker 15: No one in my life had spotted that I had ADHD. I went 25 years of being undiagnosed.

Brian Lehrer: Leon, since I jumped in and interrupted you to play that montage, do you want to stick the landing and say anything about it?

Leon Neyfakh: I just think there's a little bit of irony, in that this thing on our phones that is destroying our attention spans is also serving as the answer for some people. They're finding on TikTok and on social media people who describe them to themselves and say, "Hey, does this ever happen to you? Does this ever happen to you?" Then I think it really convinces a lot of people that they have ADHD and that they should go get assessed.

I don't know, it's almost like it reminds me of the screen time alert that we now all get on Sundays from our iPhones, that tut-tut at us that's for the 16% rise in screen time that you allowed last week. It's selling you the problem and the solution at once.

Brian Lehrer: Arielle, take our last 20 seconds and say anything you want, maybe about the shortage of the medications, which we didn't really get to. We mentioned it, or anything you want to say, as people have now heard some excerpts from your podcast.

Arielle Pardes: Totally. I think the topic of ADHD is one that is very rich at any time, but especially right now, because of the stimulant shortage. For the past two years, it's been incredibly hard for people to reliably fill their medications for ADHD. The reasons for that are complex. There's a lot going on on the supply side, but for us, it really felt like an occasion to look at the demand. Why do so many more Americans rely on these medications today than they did just a few years ago?

We hope that listeners of the show will find that we've given this a very rich, nuanced, historical narrative treatment that answers that question.

Brian Lehrer: Arielle Pardes and Leon Neyfakh, journalists and co-hosts of the podcast Backfired, Attention Deficit. Thank you so much for sharing it with us.

Leon Neyfakh: Thank you for having us on.

Arielle Pardes: Thanks for having us.

Brian Lehrer: Brian Lehrer on WNYC. Stay tuned for Alison.

 

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