Beyond the ADHD Headlines: A Nuanced Look at Diagnosis, Drugs, and Daily Life

By Michael P. Milham, MD, PhD
Chief Science Officer, Child Mind Institute

ADHD is not a homogeneous condition, as the article rightly stresses. As with many clinical conditions, each child’s genetic, brain-based, and environmental influences blend into a distinct profile. One child might have more impulsivity or hyperactivity that are obvious in the classroom and on the playground. Another might have inattentive traits that they are able, with great effort, to hide. Children also differ in cognitive abilities and in co-occurring conditions they might have. That’s why thorough evaluations — spanning different settings — are vital. We need to rule out other causes of inattention (like anxiety or trauma) and ensure we’re capturing the child’s full spectrum of strengths and needs.

That heterogeneity is why the treatment of each child focuses on the real impairment they are experiencing. For many children, well-managed stimulant medication can be a game-changer. It reduces the “noise” of inattention or hyperactivity so kids can develop coping skills and improve self-regulation. It can boost their self-esteem and ability to function in the family. Virtually all authorities agree that medication should be part of a multimodal treatment plan, accompanied by support when and where kids are struggling, including behavioral interventions. Sometimes, the child’s environment, such as a high-demand setting, will heighten ADHD symptoms and can be modified. Adjustments such as smaller class size or more physical activity can have a big impact.

ADHD is a disorder that can impact far more than a child’s report card. Families often seek help not solely for problems in the classroom, but also because their child struggles at home, with hyperactivity and difficulty following rules, managing emotions, and handling social situations. And ADHD is not only a disorder of childhood. Research shows that untreated ADHD in adults elevates risks of car crashes, substance misuse, accidental injuries, and workplace challenges later in life. At all ages, ADHD symptoms vary by setting, but they can create significant distress and real consequences that require meaningful support.

Large-scale research consistently confirms that, on average, the brains of individuals with ADHD are subtly different in structure and function compared to those without the disorder. These differences often involve brain circuits crucial for attention, executive function, and impulse control. Like brain imaging findings for most other mental health conditions, the effect sizes are modest, and there’s significant overlap between individuals with and without ADHD. The takeaway? We still lack any single biological marker, or “brain scan test,” that can reliably diagnose ADHD in an individual child or adult. While ADHD involves genuine neurobiological factors, its complexity and heterogeneity mean there isn’t a simple, one-size-fits-all biological test. We’re making leaps in understanding ADHD at a group level, but we need more refined tools to pinpoint treatment paths for each child.

Recent decades have seen incremental increases in ADHD diagnoses. Data from the CDC’s 2022 National Survey of Children’s Health indicated about 1 in 9 US children (11.4%) had ever received an ADHD diagnosis, roughly a million more than in 2016. Some of this increase is likely due to better awareness and more comprehensive screening. But environmental changes — like shifting school demands or pandemic disruptions — can also bring ADHD symptoms to the forefront in children who might otherwise have flown under the radar. Even kids with mild ADHD may feel overwhelmed if their environment is too demanding. A supportive setting can buffer them, while a stressful one can worsen symptoms.

Being alert to overdiagnosis can prevent labeling every restless child as having ADHD. But caution shouldn’t overshadow those who genuinely need help. The key is thorough evaluation to confirm persistent, clinically significant impairment, rather than transient restlessness or stress. Families also deserve an honest picture of our current science: While data-driven, personalized care is promising, it’s still years from daily clinical practice.

The Times piece cites the results of the decades-old landmark Multimodal Treatment Study of ADHD (MTA), which demonstrated the effectiveness of stimulant medication for ADHD, as well as follow-up analyses that seemed to show no benefits after the three years of clinical treatment through the study.

But what that result showed was not that stimulants abruptly stop working after three years. It showed that medication effectiveness hinges on careful, systematic management — including correct dosing and regular monitoring — alongside therapies that address behavior and environment. In follow-ups after the study, insufficient dosing and a lack of follow-through, often seen in less structured community care, can explain many disappointing outcomes. The study also supported the value of combining medication with behavioral therapy for optimal outcomes, especially for improving behavior, parent-child interactions, and social skills.

The Times article closes with a recommendation that we conceive of ADHD as a mismatch between a child and his environment, and a prediction that in different environments, over a lifetime, people with ADHD may not always need stimulant meds to do well. This is certainly true — it’s an aspect of our increasingly nuanced understanding of the disorder, and the heterogeneity in the ways it presents.

That’s why it’s important to see stimulant medication as one tool — not the only tool — we have to help people with ADHD thrive. All children respond differently to changes in environment, and in the course of growing up many people with ADHD succeed in finding environments and roles in life that play to their strengths and minimize their struggles. At the Child Mind Institute, it’s our job to set them up with as many strengths and coping skills, and as much confidence, as we can to enable them to grow into their full potential.