“Rethinking ADHD” Misses the Mark: A Clinician’s Response to the NYT Article by Paul Tough

AcademicAlly, LLC: April 22, 2025

Individuals who live with ADHD face daily challenges related to their neurodivergence:
time blindness, disorganization, lack of personal accountability, impulsivity, etc.
Unfortunately, the symptoms they encounter are nearly the tip of the iceberg as this
demographic is (and has been) encountering policy challenges that call into question
the validity of this neurodevelopmental disorder along with access to treatment, loss of
school and work accommodations, and a decrease in insurance coverage. One cannot
overlook the dramatic shortage of available medication, a lifeline for so many who have
ADHD. Stimulants medications have become harder and harder to come by, leaving
many without appropriate dosages, leaving them susceptible to engagement in
challenging and potentially dangerous situations.

What further complicates the situation is inaccurate journalistic coverage of this
disorder. In a recent New York Times Magazine article, entitled “Have We Been
Thinking About ADHD All Wrong?”, writer Paul Tough proposes that ADHD and how it
has been diagnosed and treated is not effective or beneficial. While it is always helpful
to re-evaluate how any medical, neurodevelopmental, or psychological diagnosis is
evaluated and treated, if the mechanism by which one is distributing such information is
seriously (and potentially dangerously) inaccurate, such a piece does more harm than
good. As many well-known professionals who are well-versed in the field and study of
ADHD took to the airwaves to comment on this article, including Russell Barkley, I felt
validated in my opinion of Tough’s report: it undermined the many decades of research
dedicated to the study of this disorder as well as the very real experiences of those who
live with it.

In a four-part commentary on his YouTube channel, Barkley lays out the facts and
where Tough got it so very wrong:
ADHD is Not and Arbitrary Diagnosis: Tough indicates that loose guidelines are used to
diagnose this disorder as there is “no single biological marker” to indicate its existence.
Barkley states that similar to most psychiatric disorders, ADHD is diagnosed using “standardized, evidence-based clinical criteria” (as found in the DSM-5). These are
corroborated by behavior rating scales, interviews with the individuals themselves as
well as their family members and (in the case of school-aged children) teachers, and
developmental histories. This assessment process is far from the willy-nilly approach
Tough suggests in his writing.

Barkley goes on to discuss the MTA (Multimodal Treatment of Attention Deficit
Hyperactivity Disorder) Study conducted by Joseph Swanson. This study was used to
support the idea that the benefits of utilizing medication are short-lived. In reality, the
MTA study initially found that the most effective course of treatment was to combine
medication and behavioral therapy. However, a flaw of the MTA study was its design:
participants were broken into four core groups-placebo (no treatment at all), behavioral
intervention, medication, and a combination of behavior and medication. Over the
course of 14 months, these groups received (or didn’t in the case of the placebo group)
their treatment. At the end of 14 months, the participants had the freedom to discontinue
their treatment or change the treatment they wished to utilize. The study went on for
four years, so as time passed beyond the 14 months, the results were “muddied”
because participants weren’t required to adhere to any strict protocols for treatment. As
Barkley points out, “inconsistent use doesn’t mean the treatment doesn’t work.
The next point that must be addressed is Tough’s assertion that medication is ineffective
and addictive. After one to two years of use, patients frequently stop using their
medication to address their symptoms. If the medication in question is truly addictive,
then people would not be able to abandon them so quickly. As to the notion of efficacy,
Barkley states that the proper treatment of ADHD with stimulants actually lowers the risk
of substance abuse by addressing some of the core issues people living with ADHD
struggle with including impulsivity, anxiety, and depression, all of which can lead to self-
medication.

As to the dramatic rise in rates of ADHD diagnoses, Tough suggests this is reflective of
a social trend, stating that “these [diagnoses] are to some extent arbitrary” is a
dangerous and misguided assertion-see my comment earlier about the regimented
screening process that guide clinicians’ evaluations of their patient. Rates of diagnoses
have definitely increased (according to Barkley and other reputable sources rates are
up from 3% in the 1980’s to today’s rate of 5-7%) but for good and clinically-
substantiated reasons. Researchers now know how to more effectively recognize ADHD
across age, gender, and racial lines. Adults, who were not successfully evaluated (if at
all) as children have now received proper diagnosis and intervention. Historically,
because women and girls tend to demonstrate the distracted symptoms of ADHD, they
go undiagnosed. They are not engaged in the stereotypical disruptive behavior that
many associate with ADHD. This is not overdiagnosis, as Barkley rightfully points out; it is equity. The people who have this disorder are finally receiving the attention and care
they need to function effectively in their daily lives.

Any responsible writer needs to ensure his sources are current and accurate. Tough
uses outdated research to support his assertions. For example, he cites a study
conducted by Hinshew and Lambert which is over twenty years old, and fails to
incorporate current research, denying readers the chance to view the current research
landscape of ADHD. Swanson’s work, upon which Tough relies heavily, is “cherry-
picked” from the older phases of the researcher’s work, failing to acknowledge a
broader consensus of other researchers or more current data. Equally as important is
Barkley’s recognition of the fact that Tough did not actually interview any of the
researchers whose studies he cites in his article. This leaves a lot of room for
misinformation and little opportunity to delve more deeply into the topic, which would
have afforded Tough the opportunity to check his facts and more accurately report on
ADHD.

What I find so troubling about this article is the fact that it has the potential to cause
significant harm to the individuals who live with ADHD as well as their families. They
cast doubt about possible courses of treatment- most professionals like myself and
Barkley endorse the most effective treatment plan is four-fold: once the diagnosis is
made, the individual and their family members need to be educated about the disorder,
how it can impact daily living, and treatment options; medication may or may not be
appropriate, depending on the individual’s age and how the person is presenting
(regardless, it should be discussed, including the benefits and risks associated with
taking it); behavioral interventions by way of cognitive therapy or (preferably) coaching
need to be included in the treatment plan; and finally, accommodations in the places the
individual spends most of their time (ie work, home and school) must be discussed and
implemented.

Articles like Tough’s can prevent individuals from seeking and receiving the care they
need. This can lead to dangerous decisions related to impulsivity including drinking and
driving, inappropriate texting, and self-medication with alcohol and illicit drugs, among
other troubling behaviors. Without proper care, individuals with ADHD are destined to
suffer.

Tough’s article was misleading, and the takeaway is not that professionals and
researchers like me are getting ADHD wrong, rather that he and the New York Times
Magazine got it wrong about ADHD.

ADHD is real. It is not limited to one arena of an individual’s life; it affects every facet of
the human experience. As such, it must be addressed and respected as we do any
other “legitimized” diagnosis. As Barkley rightfully points out, “science, not speculation,
must lead the conversation.” It is critical that any reporting that is written about this neurodevelopmental disorder is accurate so that people who live with ADHD and the
greater society are properly informed.