Yet Tough, throughout the article, and in later remarks in an interview with Adam B. Kushner for his morning newsletter for The New York Times, is reluctant to reach his own conclusions, and presents the material in carefully couched language such as “most researchers I spoke with believe that stimulant medications are, on the whole, a positive thing for children with ADHD.” And: “most scientists I spoke to agreed that the condition is produced by some combination of biological and environmental forces.”

This kind of hedging is understandable given the sensitivity of the topic for the families involved, and it accurately reflects the medical rhetoric, though not the science. Scientists can believe and agree to all kinds of things that aren’t based on evidence. And they have a powerful incentives to do so — institutional inertia, the difficulty of speaking out against a popular consensus, and the financial interests of their institutions and the pharmaceutical companies, to name just a few. However, if we want to slow the flood of pills — and, most important, help American schoolchildren, especially boys — we must fight the tendency to temporize.

Tough is the author of several books on education and child development, and is a meticulous researcher and long-form feature writer of the highest professional standing. He spent a year compiling the story, which is worth reading in full, and which appears to represent the most reputable, thorough, and mainstream analysis of today’s science. In it, he documents a situation that most American families are aware of — an explosion in ADHD diagnoses, which last year spiked to 11.5% (or 7 million kids), up from about 3% (or 2 million kids) in 1993.

Of those diagnosed, a disproportionate share are boys: 21% of 14-year-old boys and 23 percent of 17-year-old boys officially have ADHD, according to 2024 figures. The actual number displaying the collection of symptoms associated with ADHD is probably much higher, given that not all families pursue a formal diagnosis. Tough does not provide hard numbers on what percentage of those diagnosed are taking prescription stimulants such as Ritalin or Adderall, but says that it’s the “preferred” treatment.

More from this author

Test article

By Valerie Stivers

Most Americans aren’t aware, however, of the sketchiness of the underlying science — which has always seemed pretty obvious to dissenters, but has now been conclusively demonstrated. The field started, Tough says, with an observation, made by a Harvard-trained psychiatrist in 1937, and since very widely replicated, that giving amphetamines to children classified as having behavioral problems has the “spectacular” effect of getting them to sit down and stay cheerfully focused on a task. Skeptics have pointed out that stimulants do that to everyone, and are popular precisely with people who wish to get through boring tasks more pleasantly (long-distance truckers, Fifties housewives, every college student unprepared for an exam).

Nonetheless, the ideas that the source of the children’s noncompliant behavior might be a physical deficit, and that the drug might correct it, has been compelling. Since the Nineties, massive amounts of research has gone into proving this attractive proposition by looking for a biomarker for ADHD (such as a gene or a correlation such as “less brain electrical activity”) and scientifically demonstrating the benefits of the treatment.

Initial results were promising, Tough writes. The Multimodal Treatment of Attention Deficit Hyperactivity Disorder Study, launched in the early Nineties and funded by National Institute of Mental Health, was “one of the largest studies ever undertaken of the long-term effects of any psychiatric medication.” In 1999, the researchers announced early results that Ritalin, their stimulant of choice, produced “significantly fewer symptoms” in children with ADHD after 14 months, compared to comparison groups of ADHD kids receiving only behavioral training or no interventions at all.

In 2017, in an effort to find a biomarker, an analysis of brain scans performed by the Enigma Consortium, a global network of scientists, announced that “patients with ADHD have altered brains; therefore ADHD is a disorder of the brain.” This was the “most ambitious” project to date, per Tough. However, his more recent conversations with the scientists who participated in those projects reveal a different story.

The brain-scan differences, he says, were either nonexistent among adults or “so minor as to be almost imperceptible” among children. Martine Hoogman, a Dutch neuroscientist who led the Enigma team, wrote to Tough in an email: “‘Back then, we emphasized the differences that we found (although small), but you can also conclude that the subcortical and cortical volumes of people with ADHD and those without ADHD are almost identical.…’ In retrospect, she added, it wasn’t fitting to conclude from her findings that A.D.H.D. is a brain disorder.”

As time passed, the MTA began to turn up different results. By 36 months on stimulants, improvements in children’s behavior had disappeared — in fact, children in all three groups demonstrated “exactly the same” level of symptoms. Moreover, careful observation of the children in question revealed a diagnosis in flux. As later studies have shown, sometimes they seemed to have ADHD, sometimes they didn’t. Sometimes children in a comparison group — who didn’t have it at the study’s outset — developed it. Tough quotes Edmund Sonuga-Barke, a researcher in psychiatry and neuroscience at King’s College London, as saying that “the traditional notion that there is a natural category of ‘people with ADHD’ that clinicians can objectively measure and define ‘just doesn’t seem to be the case.’”

At the same time, situational explanations for the behaviors have seemed to grow in significance. A 2016 study published by researcher Arielle Lasky and members of the MTA group, Tough writes, interviewed adults in their mid-20s who had participated in the study as children. “Subject after subject spontaneously brought up the importance of finding their ‘niche,’ or the right ‘fit,’ in school or in the workplace,” he says. When the subjects found pursuits that were more interesting to them than school had been, their symptoms disappeared. Given such results and the difficulties of finding a biological cause, Sonuga-Barke proposes that we view ADHD not as a medical problem, but one of “misalignment” between what he tactfully calls “a child’s biological makeup” — but could also easily be called a child’s personality and situation in life — and “the environment in which they are trying to function.”

More disturbing information has come out as well. The MTA study found that after 36 months, children in the group taking Ritalin were on average one inch shorter than children in the control groups, and that the height lost was not made up later — they were still shorter as adults. And last year, a study published 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.

Several studies have also debunked the appealing assumption that better classroom behavior actually translates to better learning. Children work faster and behave better, but Tough’s conclusions are mostly reflected by the words of F. Xavier Castellanos, a neuroscience researcher at New York University, whom he quotes: “There’s a real disconnect between the almost awesome effects on behavior and the minimal effects on academic achievement or attainment.” A 2023 study on adults found subjects’ strategies for problem-solving became “significantly worse under the medication.” It shouldn’t take a neuroscientist: Most people with any experience with recreational drugs in this category have noticed the same effect.

So why is the overall consensus, as Tough represents it, still so gentle in taking on the status quo? Why do the researchers still believe or agree that the medications are beneficial? And why does someone as smart as Tough introduce paragraphs with careful sentences such as “the failure to find a clear biomarker doesn’t mean that there is no biological basis for ADHD”?

In most human affairs, the burden of proof is on those arguing for something; we aren’t required to prove a negative to move on from a bad idea. Sonuga-Barke theorizes that research priorities have been distorted by the urgency of the children’s distress and the families’ needs for a solution. “In the field, we’re so frightened that people will say it doesn’t exist,” he told Tough, referring specifically to the quest for the biomarker. “We have to double down because we’re terrified of what will happen to the kids who can’t get the meds. We’ve seen the impact they can have on people’s lives.”

More from this author

Adderall is not an identity

By Oliver Bateman

There is, however, urgency to a change of direction. For one thing, doctors who “believe” that stimulant medications are “on the whole, a positive thing” are unlikely to arm families with the information they need to make fully informed choices about their child’s health. The obfuscating language in Tough’s story surely is being replicated throughout the medical establishment. As James Swanson, a research psychologist who worked on the initial MTA study, told Tough, “If you’re honest, you should tell kids that, look, if you’re interested in next week or next month or even the next year, this is the right treatment for you. But in the long run, you’re going to be shorter. How many kids would agree to take medication? Probably none.”

And for another, the situation looks very different when you admit that the problem is not a physical deficit of some kind, but something afflicting a large share of children and, by my guess, most teenage boys. Diagnosing and possibly medicating these kids may get them through a bad time more successfully — it’s clearly a lifeline for many struggling families — but it does nothing to prevent the problem from arising, or to help the kids learn.

In his book The Quick Fix: Why Fad Psychology Can’t Cure Our Social Ills, which analyzes debunked science crazes in illuminating detail, the journalist Jesse Singal discovered that “at root, when society accepts a false story, it’s often because that story tells society something it wants to hear.” He also observes that it’s a pattern for junk science to be taken up when it provides “an easy way out” of a complicated problem.

In this light, we might conclude that ADHD has been an easy way to address (or not address) the vastly complicated problem that contemporary school is unsuited to the needs of a large percentage of the child population, especially boys, and desperately needs reform. We might target our attention on the long, physically confining days; the constant usage of attention-shattering screens; the stultifying conformity; the chaos-promoting soft-discipline; and the deeper questions, exacerbated by AI, of what any of it is doing and what it’s for.

Or we might target other things. But to target anything, we have to move the blame off the kids, where it never should have been in the first place. Our children’s bodies and personalities are not deficient. We are.

Neither my wife nor I use Adderall with any regularity. A 60-count “break-in-case-of-emergency” supply might last the Bateman family ‘til death do us part. But the same cannot be said for millions of others who are reliant on the drug: since last August, the world has experienced a shortage of Adderall. This is probably tied to manufacturing and supply chain issues combined with rapidly increasing demand — though nobody knows for sure. It has had a particularly acute effect on the US. A high-income country of 330 million people is bound to have an outsized impact on world affairs. But the numbers related to Adderall beggar belief. America consumes 80% of the drug’s global supply. Back in 2013, there were 18 million Adderall prescriptions in circulation in the United States — a number that exploded to 41.4 million in 2021.

These statistics can be partly explained by another equally astonishing set, relating to the condition for which Adderall is prescribed. According to the US Centers for Disease Control and Prevention, 6.3% of US children aged 5-9 have ADHD, compared to 1.5% of UK children aged between 6-8. Some attribute that to differences in diagnostic principles. The criteria used in the US are considerably more detailed, allowing for diagnosis only if at least five symptoms are present, whereas the globally-accepted standard gives more leeway to the clinician, only stating that symptoms should be “sufficient in number” and cause “significant psychological, social, educational or occupational impairment”.

When I asked one therapist why this leads to a much higher number of ADHD diagnoses in the US — rather than the opposite — she pointed to the laws governing education. Here, the Individuals with Disabilities Education Act mandates that schools provide special education services and accommodations to students with ADHD, while in the UK, there’s no specific legislation for ADHD, and schools have more flexibility to support students with diverse learning needs without a formal diagnosis. American doctors know that parents and students need this diagnosis for paperwork purposes, so they, to borrow a line from Jean-Luc Picard, “make it so”.

In other words, an ADHD diagnosis opens a lot of doors in the US. If you know what to say, it’s not hard to get Adderall. And there are plenty of reasons to want Adderall. It significantly improves cognitive function, increases wakefulness, and enhances mood — temporarily turning poor learners into decent ones, and good ones into rock stars. Longer-lasting than other ADHD drugs like Ritalin, Adderall offers that intense “clear” feeling I mentioned, resulting in higher levels of focus, attention, and motivation.

These stimulants can improve, among other things, performance on various standardised tests that (at least for now) still have an outsized impact on admission to the most prestigious academic programmes. Unsurprisingly, there’s plenty of evidence that rich parents and their kids are working with willing doctors to secure easy access to Adderall, and other so-called “smart drugs”. A 2016 study found that 10.7% of high school students who had used Adderall in the past year had obtained it from a doctor. Meanwhile, 13.2% had obtained it from a friend or family member, indicating that these drugs circulate widely in certain academic and social circles — a fact many of us may know all too well.

I’ve watched a number of friends and relatives game the system to receive legal prescriptions for ADHD, visiting physicians and uttering the magic words needed to meet diagnostic criteria. Their motivations varied: one cousin likes to be “amped up” on stimulants at all hours of the day, while a friend from college uses it to improve his performance as an esports athlete. And I’m willing to admit that the drug has benefited me in small and very infrequent doses. But there are obvious ethical concerns here. Adderall, like Ozempic (for weight loss) or testosterone (for muscle building), gives some people an unfair advantage over others.

More from this author

The Ozempic class war has begun

By Oliver Bateman

The US Drug Enforcement Administration acted last month to rein in what some now consider a “Wild West” environment. Adderall prescriptions in the US rose 16% during the pandemic, with telehealth appointments a main driver. The DEA’s proposed rule would require at least one in-person visit to the physician prescribing controlled substances such as Adderall. But it faces stiff resistance from clinicians and users, who argue that remote consultations increased access to life-changing medications. People whose lives and identities are tied up in ADHD have been lamenting that their condition, defined by an inability to focus without Adderall, becomes doubly hellish when they’re required to actually go somewhere to get prescriptions filled; the complaint of one legal aid attorney, representative of thousands of others, was that the “nationwide adderall shortage means I skipped my doses this weekend and fucking fought for my life to do the dishes”.

And yet, the rate at which Adderall is prescribed in the US must mean that the majority of diagnosed cases of ADHD are not life-destroying, merely life-affecting. Moreover, even long-tenured experts on ADHD, including Remembering Ritalin author Lawrence Diller, have serious qualms about the “realness” of the “disease”. In his book, Diller reflects on the various young patients — “Generation Rx”, he calls them — with whom he worked during the Eighties and Nineties, probing the extent to which ADHD is a legitimate diagnosis or an oversimplified, harmful label that could be applied to anyone in certain conditions. “For patients, if ADHD truly exists, risking their health by taking a drug to treat the condition or disease makes a lot more sense… [but] if it doesn’t exist, then perhaps they’re just using it as a crutch… and setting themselves up to abuse it,” he writes. Adderall, like other stimulants, presents numerous dangers: side effects that run the gamut from high blood pressure, increased heart rate, panic attacks, psychosis, agitation and irritability. And of course, there’s the horrific feeling of crashing when one doesn’t have regular access to the stimulant.

Diller’s concerns are echoed by my neurologist acquaintance. ADHD, like most diseases of the mind, are “all in one’s head”: the symptoms are not verifiable by any methods beyond the claims of the patient. Physicians have a duty to take these claims seriously, but it’s difficult to gauge the roots of a symptom from the outside. Is lack of concentration, far from being a “disease”, merely a sign that someone is a poor student — a sad but unavoidable fact of life that one must confront in the ordinary course of existence? And if so, would liberally prescribing this now-scarce drug be the ethical thing to do? Or would that be unfair on those who use Adderall to get through the day, rather than excel?

These are loaded questions, but important ones. In response to the Adderall crisis, the media has pumped out nuts-and-bolts policy proposals. A recent New York Times column, for instance, argued for maintaining full telehealth physician availability and boosting Adderall production by shifting regulation and oversight from the DEA — which is primarily interested in drug interdiction — to the FDA — which is more concerned with drug safety and access. There is certainly much to recommend such arguments. The libertarian, “government is the problem” side of me favours wide latitude with regard to drug access, but that doesn’t acknowledge the core cultural questions fuelling all of this feverish pill-popping.

Suggested reading

Mental illness doesn't make you special

By Freddie DeBoer

It’s hardly surprising that increasing numbers of people are struggling to concentrate. We are bombarded with stimuli, which naturally leads to difficulty focusing and increased impulsivity in day-to-day life — symptoms of ADHD — and the subsequent prescription of Adderall. If assigned, a diagnosis can become a core plank in an individual’s sense of self; as Freddie deBoer has written for UnHerd, our very online culture encourages people to turn diagnoses into identities. Viewed this way, Adderall’s is a toxic, “ouroborotic” cycle of consumption — the culture fosters the behaviours that result in an ADHD diagnosis, Big Pharma sells you the medication needed to address it, and the various social media platforms that monetise your freely-provided content offer you space to earn attention by #ShoutingYourStigma.

Are you your disease — as a young influencer might proclaim on TikTok — and therefore entitled to Adderall access as some sort of fundamental human right? By extension, is someone who has the attention span of a feral cat that’s locked onto its prey not entitled to this “smart drug”? Or should everyone have access to Adderall, since it’s a tool that might encourage further human flourishing, before we’re forced to insert neural implants and merge with AI? Or should no one, since our “human essence” is sacred and must remain unsullied by chemical interventions?

These are the questions we will need to answer. But for now, all we can be sure of is that fewer people will get Adderall, particularly cheaper generic-brand Adderall, than want it. Those that do will probably be the richest — who may use it to get richer — rather than those who most need it. We can only hope that these dynamics will encourage us to reflect on whether wanting and needing, like our illness and our selves, are inextricably linked, or merely connected because “thinking makes it so”.