Why Have We Been Thinking About ADHD in Such a Limited Way?

Sunday, April 13, 2025. This is for Mason, Mariano, and all my kids at my public health clinic.

In the beginning, there was chaos. And Ritalin said, "Let there be focus," and lo, the child sat still. And there was much rejoicing. For a week.

Let us begin with the grand American tradition of solving complex socio-environmental problems with prescription drugs.

Enter your typical 1990s research psychologist, James Swanson.

A decent man in a lab coat, probably wore corduroy blazers, believed in graphs. He thought 3% of kids had ADHD and that Ritalin helped.

Not cured. Helped. That was the dream.

Then he blinked, and it was 11%. Now it's 15.5% of adolescents, 23% of 17-year-old boys, and somewhere, a pharma executive is buying his fourth house in Aspen.

The MTA Study: A Glorious Beginning, a Grim Middle, a Forgotten End

​The Multimodal Treatment Study of Children with Attention-Deficit/Hyperactivity Disorder (MTA Study) was a landmark, long-term clinical trial funded by the National Institute of Mental Health (NIMH).

Initiated in the 1990s, it remains one of the most comprehensive studies on ADHD treatment to date.​National Institute of Mental Health+5JAACAP+5Pediatrics Publications+5

Overview

The MTA Study enrolled 579 children aged 7 to 9.9 years diagnosed with ADHD, Combined Type.

Conducted across multiple sites in the U.S. and Canada, participants were randomly assigned to one of four treatment groups:​JAACAP+2yfrp.pitt.edu+2PBS: Public Broadcasting Service+2

• Medication Management (MedMgt): Carefully monitored stimulant medication.​Pediatrics Publications

• Behavioral Therapy (Beh): Intensive behavioral interventions.​Pediatrics Publications+1PBS: Public Broadcasting Service+1

• Combined Treatment (Comb): Both medication and behavioral therapy.​yfrp.pitt.edu+5Pediatrics Publications+5PBS: Public Broadcasting Service+5

• Community Care (CC): Standard treatment available in the community.​PBS: Public Broadcasting Service+1yfrp.pitt.edu+1

The active treatment phase lasted 14 months, followed by long-term follow-up assessments extending up to 16 years.​ yfrp.pitt.edu+1Pediatrics Publications+1

Key Findings:

• Short-Term Outcomes: After 14 months, the MedMgt and Comb groups showed significantly greater improvement in core ADHD symptoms compared to Beh and CC groups.

  The Comb group also demonstrated modest advantages in areas like anxiety, academic performance, and social skills over MedMgt alone. ​Pediatrics Publications+1PBS: Public Broadcasting Service+1

• Long-Term Outcomes: Over time, the initial advantages of MedMgt and Comb treatments diminished.

  By the 8-year follow-up, differences among the original treatment groups were no longer statistically significant in most outcome measures.

  Instead, early symptom trajectory emerged as a stronger predictor of long-term outcomes. ​ScienceDirect+2Pediatrics Publications+2JAACAP+2

• Symptom Fluctuation: Approximately 64% of participants experienced fluctuating ADHD symptoms into adulthood, with periods of remission and recurrence influenced by environmental demands and individual factors. ​Psychiatrist.com

Implications

The MTA Study underscores the importance of personalized treatment plans for children with ADHD.

While medication can be effective in the short term, combining it with behavioral therapy may offer additional benefits, especially for kids with co-occurring conditions like anxiety or oppositional behaviors.

Long-term management should consider the evolving nature of ADHD symptoms and the influence of environmental factors.​National Institute of Mental Health+3yfrp.pitt.edu+3ScienceDirect+3PBS: Public Broadcasting Service

For more detailed information, you can visit the NIMH's official page on the MTA Study.​

In other words, the early data said stimulants worked. Kids behaved better.

Teachers stopped crying.

Parents felt like they'd found salvation.

But science, being a relentless bastard, kept asking inconvenient questions.

The big one: What happens after the first 14 months?

Answer: absolutely nothing.

The medication effect fades like your New Year's resolution by mid-February. At 36 months, every group in the M.T.A. study — medicated, unmedicated, behaviorally coached, or just left alone to marinate in their chaos — looked the same.

That is, equally distracted, fidgety, and unfinished in their math homework.

Swanson, at the age of 80, now sounds like a man delivering a eulogy for his career: "There are things about the way we do this work that just are definitely wrong." Translation: I've spent decades feeding a machine that eats children and sh*ts out marketing copy.

The Biomarker Mirage: Searching for Science in the Desert of Confirmation Bias

Meanwhile, academics like Edmund Sonuga-Barke are wondering if the whole biological model of ADHD is a red herring.

Well, it just might be.

But no one wants to say it because no one wants to be the guy who took away Jimmy's Adderall the week of finals.

Let us not forget the grotesque irony: Scientists kept trying to find biomarkers. Smaller brain volumes, wobbly EEGs, naughty genes.

But replication studies failed. The Holy Grail turned out to be a sippy cup.

Martine Hoogman found no significant brain differences, but still claimed her data confirmed ADHD as a brain disorder.

Why? Perhaps because it clearly makes parents feel better. We have, as a culture, somewhat confused "reassurance" with "truth."

What Ritalin Really Does (Hint: It’s Not Learning)

So what does Ritalin actually do?

According to one student, it made SAT prep feel like falling in love.

According to history, amphetamines have always helped people tolerate boredom: war, housework, truck driving, algebra.

Studies confirm the punchline:

On Ritalin, kids behave better and do more worksheets, but they don't actually learn more.

It's the educational equivalent of a treadmill desk — very busy, but you're not going anywhere.

Let us pause and reflect on the sheer absurdity of a treatment that helps a child look more focused while having zero impact on their ability to learn, understand, or retain information.

What we call "treatment" might better be labeled "performance-enhancing compliance."

The Long-Term Fallout: Smaller Kids, Bigger Problems

And the long-term?

Let's talk growth suppression. A full inch shorter by adulthood.

Also: increased risk of psychosis, addiction, and the slow flattening of one's social spark into an emotionally beige existence. But hey, at least you finished your SAT practice test.

ADHD Is a Moving Target: Welcome to the Fluctuation Zone

The real kicker is that ADHD symptoms fluctuate.

Only 11% of diagnosed kids consistently met the criteria over time.

Symptoms came and went like bad fashion trends. And 40% of the non-ADHD kids in the control group eventually crossed the diagnostic threshold at some point.

Surprise! Being a kid is hard sometimes.

Environment, Not Disorder: Rethinking the Real Problem

Researchers found that kids thrived not when their brains were altered, but when their environments changed.

Film students no longer struggled with attention. Hairstylists could memorize lectures about haircuts. Auto mechanics found their groove with grease and gears. These weren’t broken brains. These were misfit contexts.

This is the radical idea: Maybe the issue isn't that children have faulty attention mechanisms. Maybe the issue is that childhood has been re-engineered into a test-driven, desk-bound meat grinder designed for industrial conformity.

The New Model: Person-Environment Misfit

Dr, Edmund Sonuga-Barke now proposes a model where ADHD. is less about biological defects and more about person-environment mismatch.

This, of course, makes him sound like a 1970s radical therapist in corduroy with a John Lennon poster on his wall. But it might also make him right.

A diagnosis, under the old medical model, says: "You are broken. Take this pill."

Under the new model, it says: "You are different. Let's find a place where your difference thrives."

Medication as Performance Enhancer, Not Cure

And here comes the sadistic punchline: The medical model is often more comforting to parents, because it provides a concrete, medicatable answer.

It lets us say, "It's not bad parenting. It's biology!"

But to a child, the medical model often feels like a sentence.

A defective-brain identity. A lifelong prescription pad. An inch shorter and a laugh less funny.

Swanson, now more confessor than clinician, says it plainly: "There is no long-term effect. The only long-term effect that I know of has been the suppression of growth."

What We Should Say Instead: A Deeper Honesty

If we were honest, we'd say this: Medication is a short-term tool that helps some people function in systems designed for none of us.

It's caffeine in pill form, with better marketing. It works if your goal is to endure boredom without screaming.

It does not make you smarter, happier, or more connected to your own life.

And the research increasingly points to a deeper truth: Maybe we should spend less time fixing kids, and more time fixing the places they inhabit.

Be Well, Stay Kind, and Godspeed.

REFERENCES

Bowman, E., & Coghill, D. (2023). Effects of stimulant medication on strategic decision-making in young adults with A.D.H.D. Journal of Psychopharmacology.

Kazda, L., et al. (2021). The psychological impact of A.D.H.D. diagnosis: Empowerment or stigma? Social Science & Medicine, 275, 113838.

Pelham, W. E., et al. (2022). Classroom behavior and academic learning under stimulant medication: A randomized controlled trial. Journal of Abnormal Child Psychology.

Sibley, M. H., et al. (2023). A.D.H.D. symptom fluctuations across developmental stages: Findings from the M.T.A. study. Journal of the American Academy of Child and Adolescent Psychiatry.

Sonuga-Barke, E. J. S. (2022). Reframing A.D.H.D. as person-environment misfit: An alternative to the medical model. Journal of Child Psychology and Psychiatry.

Swanson, J. M., et al. (2017). Long-term outcomes of stimulant medication: A 25-year follow-up. Journal of the American Medical Association Pediatrics, 171(10), 925–931.

Vrecko, S. (2013). Just how cognitive is "cognitive enhancement"? On the significance of emotions in university students' experiences with study drugs. AJOB Neuroscience, 4(1), 4–11.

Hoogman, M., et al. (2017). Subcortical brain volume differences in participants with A.D.H.D. in children and adults. The Lancet Psychiatry, 4(4), 310–319.

Gabrieli, J. D. E. (2024). The neuroscience of motivation and engagement in A.D.H.D. Annual Review of Psychology, 75, 403–428.

Barkley, R. A. (2002). International consensus statement on A.D.H.D. Clinical Child and Family Psychology Review, 5(2), 89–111.