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Kat Johnson: Hi listeners, this is Audible Editor Kat Johnson, speaking today to the acclaimed journalist and podcast hit maker Leon Neyfakh. His latest release is from Prologue Projects and Audible Originals. Welcome, Leon.
Leon Neyfakh: Thank you for having me.
KJ: Thank you so much for being here. It's great to be talking to you today. This is your second installment in the Backfired series, which looks at the business of unintended consequences. The first installment, , took on e-cigarettes. Now you and your cohost, Arielle Pardes, are back with Attention Deficit. How did you guys land on the topic for this one?
LN: One thing we've realized over the years as we've made various historical series, especially, is the best topics are the ones that are kind of out in the ether, that people kind of half know about. They think they know about them, but they have only maybe picked up things here and there and it's formed an impression in their minds, but it's nothing compared to how much you can learn from doing a deep dive. And so, when we made The Vaping Wars, we sort of backed into this angle of "the business of unintended consequences" after deciding we wanted to do a show on JUUL and other e-cigarette brands. Because we realized that's what that story was about—it was a business story about what happens when you try to solve a problem, in that case smoking, and then end up creating a bunch of new ones that you didn't foresee.
So, in brainstorming other potential installments of Backfired we worked with our then-colleague Kim Gittleson to try to find a different kind of story. We didn't want to just repeat the same exact dynamic that we explored in The Vaping Wars. Even though there are a couple other things that we could have done that were a little bit more similar, ADHD struck us as this thing that's just everywhere right now. It used to be that you would hear about it in doctors’ offices and maybe in the teachers’ lounge or in the nurse's office or in discussions between parents and doctors and children. But increasingly it's something that adults are diagnosed with. It's a label that some people embrace in some cases because they find that the treatments really help them. In other cases, I think especially when you look at social media, it really seems to create community for people. Like, they all share a common experience of feeling limited by their minds and by their inability to focus or their propensity to procrastinate.
The definition of ADHD is quite broad, and it has to be because it has to encompass so many different things. For example, men and women manifest ADHD symptoms very differently. So, it ends up being this constellation of symptoms that a lot of people can identify with. But over the past, I would say, five, ten years, we've really seen ADHD become this cultural phenomenon.
So, to get back to your question—why did we decide this was a good season 2 of Backfired?—is that we're a long way from where we started with this diagnosis and with the drugs that are used to treat it. As we document in the show, this started as a pretty obscure childhood disorder that not a lot of people recognized or took seriously. The initial estimates of how many people are affected by it was in the vicinity of 2 percent to 3 percent of the child population. But now we're in a situation where way more kids than that are diagnosed with this condition, and adults who back in the ’60s weren't even really contemplated as potentially having ADHD are also in the mix.
Meanwhile, there's obviously a lot of worries that people have about how these drugs affect us and how people can abuse them and how they can sort of alter who you are, even if you're taking them as prescribed. And we wanted to explore that. It's not like we came into this wanting to prove that ADHD and Adderall and Ritalin were all horrible ideas that destroyed our society. As people who've heard our podcasts before, we are not idealogues, or we try to be very open-minded. And we are most interested in sort of documenting where people are coming from as they made key decisions that affect public policy and so on. So, while the frame is Backfired, I think we wanted to understand, well, did this backfire? To what extent should we be looking around at the state of ADHD in 2024 and asking ourselves if this is where we meant to end up?
One other thing I'll mention is that there's currently, and has been for a couple of years now, a shortage of stimulant medication in America. People just can't reliably fill their prescriptions, and there's different theories as to why that is. But as we came to understand it, there's a supply argument that says that we need to be producing more of this stuff, and the DEA needs to lift their restrictions on how much amphetamine and other stimulants companies are allowed to produce. And then there's a demand argument, which says maybe there's something wrong if this many people need stimulants or want stimulants. And so that's where we begin the show: like, there are these two totally opposing ways of understanding the public health crisis we're in, and we wanted to figure out how we got there.
KJ: I think it's really interesting you say ADHD is so omnipresent. It really is almost like imposter syndrome at this point—
LN: 100 percent.
KJ: —where just everybody seems to have it. I'm one of those many people who, as you mentioned in the show, were diagnosed during the pandemic and started to notice they identified with some of these symptoms, even if they had never really associated themselves with the traditional definition of ADHD before. I really appreciate how you bring some of your own personal experience to bear here. You did that more so in The Vaping Wars, but you also do it here. You and Arielle, I think, are both neurotypical; you don't have ADHD yourselves. What was your relationship to this topic personally, and then how did your perspective shift?
LN: So, as I talk about it on the show, I abused Adderall all throughout college. I started taking it as essentially a performance-enhancing drug, because I found myself not finishing my work on time, not being able to devote as much time and energy as I wanted to my reading, my homework assignments, and also extracurriculars, like working for the school newspaper. I think I remember in my freshman year I took some caffeine pills and that was before I was bold enough to try an illegal drug. Then I think maybe sophomore, junior year, is when I first started bumming pills from someone I knew who had a prescription. I would say, insofar as my goals were to get more work done and to stay up later and power through as much as I could, they helped me all the way through. But I found pretty quickly that they also caused me great angst and resulted in bad moods, to put it mildly, and trouble sleeping and weight loss because they're an appetite suppressant, so you just eat less. I kind of just felt like a shell of myself by the end of my college experience. It's hard not to regret because it is the main thing I kind of remember about college. That really made a mark on me.
"While the frame is Backfired, I think we wanted to understand, well, did this backfire? To what extent should we be looking around at the state of ADHD in 2024 and asking ourselves if this is where we meant to end up?"
I think I brought a lot of that to this reporting. Not only because it helps me you know, in the episode we do on college campus abuse, offer my own personal experiences as a data point. But I think it also created questions in my mind about other people who take these drugs without having a prescription or a diagnosis. Because a lot of people I know have incorporated these drugs into their lives. I think a big point of tension in this story is: How do you draw the line between someone who actually has ADHD and actually needs these drugs from someone who doesn't—someone who merely wants these drugs? I think I've brought some biases to how I saw people who take stimulants because I've projected a lot of my own experiences onto them.
I suppose my bias going into this show was, a ton of people who are taking these drugs "don't deserve to be on them," quote, unquote. And by deserve, I mean there's no medical reason why they should be on them. And we should be honest about that. It's not to say that I think they shouldn't be taking them just because they don't deserve to be on them, but I think I had a feeling like, "Let's be real about who really has this and who really doesn't." What I've found over the course of reporting is that it's actually a lot harder intellectually to draw that distinction. Just because you have a prescription or just because you have a diagnosis from a doctor, is that enough to say that you really have this? Or just because you don't have a prescription or a diagnosis does that mean that you don't have it? So, those lines are just a lot blurrier than I kind of assumed going in.
It was an interesting journey to go on because I feel like I understand a lot more why people are in some cases defensive about their ADHD or their use of stimulants. Because we talked to a bunch of people who said, "Yeah, you people who take these drugs for fun or in order to get more work done, you make it harder for the actual people with ADHD. You make it harder for us, not only because there's now a shortage of these drugs, but because people like you go around assuming that everyone has the same experience you do. Which is to say you don't really think anyone "really" has this, and you don't think anyone "should" be on these drugs or has a right to be on these drugs. But actually, there's a bunch of us for whom this is a life-changing treatment. It's not a discretionary indulgence or compulsion. It's a drug that makes us functional." I think that's just another interesting tension that we tried to explore on the show.
KJ: Yeah, absolutely. And thank you for sharing your experience, that's really helpful. I also think you brought up an interesting point, which the show makes as well, which is how entangled the disorder of ADHD is with the medication to treat it. Like, you can't separate them in many ways. You bring up in the show about how pretty much since the beginning the pharmaceutical marketing strategy was just as much about marketing the disorder as it was marketing the medication. In the book , [author] Johann Hari points out that for a lot of doctors they would diagnose just by putting a kid on ADHD medication and if it helped, that would indicate a positive diagnosis—where, to some of us, it's like, "Well, amphetamines are going to help you be motivated and focused." But what's going on here? Is this something unique to ADHD? Is it the meds? Is it psychiatry more broadly? Why are these so entangled?
LN: I think ADHD is unique in that the boundaries that we can draw around it are so porous and so unstable. The definition has changed over and over again as we've learned more about it. The conventional wisdom around how these drugs affect people has changed. I think it lends itself more than even something like depression or anxiety to a truly subjective analysis. At the end of the day, we can't really see what is inside anyone's mind. And to a great extent diagnosis is about self-reporting. Even when it's done systematically—there are all these what are called scales, questionnaires basically that attempt to kind of make this very subjective analysis a little bit more objective. But I think at the end of the day, people have a hard time knowing whether the label applies to them, on the margins especially. Like, clearly there are cases of people who absolutely have no question as to whether they have this disorder and that they need these medications to overcome it. But I think on the margins, people are ambivalent and a little bit unsure.
But you had another question, which was how did it happen that the drugs are so intertwined with the disorder? Why can't we talk about one without the other? I suppose one answer to this is that the drugs work so well. And as you said, they work well on everyone, whether or not they have a diagnosis or not. Everything else that you can do for your ADHD is comparatively slow and difficult and requires a real investment of time and commitment. And so any doctor you talk to will absolutely say that you shouldn't just treat this with a pill, there's other things you need to do. There's behavioral therapy, there's strategies that you can employ in how you learn and how you take notes and how you organize your day that can be just as transformative. But I think the power of a pill is hard to resist. This is just speculation, but I think a lot of the folks who are kind of marginal cases, if you told them, "There's no pill, you just gotta do all these exercises and do all this therapy," they'd be like, "Uh, all right, maybe I don't have this actually."
KJ: A lot of those exercises are not very appealing for someone who has ADHD, you're right about that. When we talk about the drugs, as you point out in the show, Adderall was really the game-changer. It worked so well instantly for a lot of people who hadn't had luck with Ritalin. It became this cultural touchstone, yet you find some evidence that Adderall isn't actually as effective as people think it is, at least for certain things. Can you tell us about what you found?
LN: So, I mean, this is tricky to talk about because it absolutely has an effect, as we've discussed. There's no question that it does something. But we reviewed research by a neuroscientist, Martha Farah at University of Pennsylvania, whom we interviewed. She was really interested in, what do these drugs actually help with? Especially when it comes to people who don't have ADHD. She was particularly interested in what she described as normal and healthy people who don't identify as having any kind of disability or disorder. And what she found was that, along various metrics related to cognition like memory, for example, it didn't really have any effect at all. It wasn't a "smart pill." What it did was it made you more confident, and it made you more motivated. As I say in the show, that really resonated with me because I remember thinking I was a genius when I was taking Adderall and thinking that it was worth writing five pages when I could've written one because that's just how good my ideas were.
Adderall, I think more than Ritalin, has been described as having a euphoric effect. People who have serious ADHD actually report not feeling that euphoria. This is a big open question as to how exactly can we distinguish between the way these drugs affect people who have ADHD versus people who don't. It's really an open question with not a lot of scientific consensus. A lot of people say there is no distinction. But anecdotally there really seems to be. I talk about a friend in the show whom I've talked to at length about this, and he takes a truly stunning dosage of Vyvanse every day. And it makes him calm. It makes him more capable of getting through his day in an orderly fashion. Whereas if I took the amount of Vyvanse that he takes I would be jumping off the walls and I would be sending emails to people, making plans that I wouldn't want to keep after the drugs wore off. I would not be myself, you know what I mean?
KJ: Right. So it does make you more confident, more motivated, but the search for the Limitless drug continues.
LN: And by the way, motivation and confidence, those aren't nothing. Sometimes you need that. Sometimes that's what it takes to get to the end of the race. But I think we imbue these drugs with maybe a different kind of power than they actually have. And again, I should clarify those studies that Martha Farah did were specifically about people who had not been diagnosed with ADHD.
KJ: That's a good point. You and Arielle speak to a lot of really interesting people for the show. I was surprised Kurt Vonnegut's son was in there.
LN: That's right.
KJ: Conor Oberst's grandfather was in there! Who were some of the people who stood out to you that you thought were incredible to have on?
LN: You mentioned Mark Vonnegut. I'd single him out as one of my favorite interview subjects because he was a member of a panel in 1998 who was called to sort of take stock of all that was known about this disorder and as part of an NIH [National Institutes of Health] consensus conference where they spent several reviewing all the data, all the different ideas about what ADHD was and how it worked. They were supposed to come up with a consensus statement that would sort of settle a lot of open questions. And during the press conference that followed this, where reporters could ask questions of the panel who had produced this report, an NPR reporter asked a very seemingly straightforward question, which was, "what does a kid who has ADHD look like? Like, what are the tell-tale signs?" And Mark Vonnegut was called on to answer because he is a pediatrician, and therefore was seen as someone who could speak to specifically this question of what do kids who have this disorder look like? How do they behave? And Mark Vonnegut gave this extraordinarily rambling answer where he was starting and stopping and getting frustrated with himself and double-backing and hedging. And it made a huge impression on people. Like, "Whoa. We asked the finest minds in this field to figure this out and this is what it sounds like?"
What I loved about Mark was that when we interviewed him about this—and this was obviously something from 1998, so it's been a million years—but Mark was like, "Yeah, I got it right. That was the correct answer" [laughs]. One of the things he said during his answer that got quoted a lot was, "The diagnosis is a mess. The diagnosis is a mess." And he was like, "It was a mess. It is a mess." And, you know, it was not an elegant answer that he gave, and he said, "I lost friends over it because people thought I had done such a disservice to the cause." But he stands by it, and I found that very powerful.
KJ: Absolutely. And it's interesting, ADHD doesn't seem like something we've really gotten much closer to solving with time. Can you talk a little bit about how the discourse back then stacks up to now?
LN: One thing we realized pretty quickly as we started researching and outlining the series is that this is a very cyclical story, in that every step of the way you see a similar dynamic playing out where some people are really optimistic and confident that these drugs are a net good and are helping people. And you also have an opposition, voices who say that this is taking us in the wrong direction, this is a scourge on society or a drug epidemic, essentially, that we can't control. I think our bias in the present is to think these are conversations we're having for the first time, in 2024. But it's just very striking to read, for example, testimony from a 1970 congressional hearing about early experiments with Ritalin on kids, and to see very similar rhetoric and dynamics playing out there and to just marvel at how little has changed in a way.
KJ: That really struck me too. As someone who actually was around in the ’80s and ’90s, I was shocked by how similar or familiar the debate was. And I think Mary Fowler, who was the ADHD advocate, just the way she spoke about it, I was like, "Wow. This could've been said yesterday." It was very resonant today. So, I think it's important for people, especially young people now, to know that we've been having this conversation for a while.
LN: Mary Fowler is interesting because she was an early parent advocate. Her son suffered from ADHD symptoms, detectable very early on in his life. And she was really reluctant to put him on medication, but then when she did, she saw a huge change and she became really a strong advocate for legitimizing these treatments and for destigmatizing the diagnosis. She wrote a memoir in, I believe 1990, and we had her read from it. One of the things she says in there is, "Don't take this lightly. Don't throw this term around. Don't attach it to people who don't need it, because when you do, you do a disservice to the people who do need it."
I think insofar as there is a sort of unambiguous truth that I have derived from making this show, it's that we can have all the arguments we want about whether it's okay for people like me, who don't have ADHD, to use performance-enhancing drugs, but the reality is that if too many people decide that they need these drugs or that the diagnosis fits them, then, Insofar as there’s a spectrum of people who have really severe symptoms, and then on the other side people who have marginal symptoms or merely a desire to get more work done, if you group them all together as people with ADHD then you do end up having an effect on the people who are at the far end of that spectrum. And not only because the supply of stimulants runs out and the people who really need these drugs can't get them, but also because I think it fuels skepticism around the disorder itself.
"I think ADHD is unique in that the boundaries that we can draw around it are so porous and so unstable."
This was kind of connected to what I was saying before about my bias going in. I think knowing so many people who don't really have ADHD who take these drugs, it made me kind of reflexively skeptical of everyone who takes them. I think that's a bias that I worked through making the show. I hope when people hear the show, they can tell that I fought back against that bias because hearing people like Mary Fowler talk about how much her son suffered, how much she suffered as a mother, feeling at the end of her rope and not knowing what to do, it really makes you realize, just because you and your friends take this lightly and treat it like coffee or whatever doesn't mean that everyone is like that.
KJ: I think that's really important to acknowledge, so I'm very glad you said that. That just the fact that we know there are people misdiagnosing themselves out there, but that doesn't mean anyone should fall under suspicion for their—
LN: Exactly.
KJ: Yeah. So, thank you for saying that. You know, your work in general involves so many different moving pieces, from research and reporting to writing and recording and having meetings and doing promotional things like you're doing right now. I know audio projects require some pretty intense focus. How do you tune out distractions when you need to get in the zone?
LN: Unfortunately, the most tried and true way for me to sit down with a script, for example, and either write or revise it, is to do it at night when there's nothing else going on. A lot of times during the day I'm talking to my colleagues, I'm in meetings, I'm doing calls, I'm doing interviews, I'm doing admin because I also run the production company in addition to hosting a lot of our shows. So, the days go by and it's hard to find a long chunk of time when you can really get in the zone. And so, often, I end up staying up late and doing that stuff when no one else is around. I know a lot of book editors or literary agents who find the same thing. Like, they bring their work home and they can only do it at home. The part of their job where they're reading is the part of their job they don't do at work.
KJ: You've said in the past that your approach to history is that of a journalist rather than a historian. As a journalist, how do you go about the reporting and the storytelling of history? Do you have any tenets or best practices you could share?
LN: Yeah. I'm really big on cause and effect. I think a lot of times what we're doing when we take on something like the story of ADHD—or when we did a series on the crisis, or the Bernie Goetz shooting of 1984 for a show called , which is under our Fiasco banner, also on Audible—
KJ: I love both those shows, by the way. Excellent.
LN: Thank you. Thank you. I think one guiding principle is we’ve got to figure out how we got from here to there. That often means really drilling down into people's decision-making and understanding what led to what, and what people were thinking at the time. I think starting with Slow Burn, which was my first podcast with my longtime colleague Andrew Parsons, we wanted to put ourselves in the moment. We wanted to experience Watergate as people experienced it during its unfolding. That meant not knowing what was going to happen next. It meant operating with incomplete information. It meant making decisions without the benefit of hindsight. I think we try to re-create that in our shows; we try to be really fair to people whom we could judge with the benefit of hindsight and try to avoid that. We try to be clear and honest about the constraints within which everyone was doing their best. Not to say we don't have storylines in our shows where it seems clear that someone acted in a way that maybe most people would disagree with. But there is a sort of spirit of empathy throughout our shows, and as we do try to disentangle cause and effect, we try to make a good-faith effort to understand where everyone was coming from.
The other thing I'll say is that the more of these we've done, the more I'm convinced of the bunch-of-people-in-a-room-theory of history. You want to believe that there's some logic, that are some larger forces acting on us that have gotten us to the point where we are. But so much of history is contingent and so much of history is the result of accidents and coincidences and personal bias and personal vendettas and personal ambitions. I think more than you'd expect, some of the most consequential changes to our society have been the result of just a couple people making choices. I think that lends itself well to a character-driven approach to history, which I think is definitely what we want to do.
KJ: Yeah, I mean, say that louder because I feel like that is also why conspiracy theories are so appealing. Because we're always trying to impose some kind of narrative on why something happened, but it could be just random, might not be a big master plan. I wanted to ask you about the medium of audio storytelling. What do you like about it? When did you start to see the possibilities of it? And what's exciting to you about it now?
LN: So, I was a print reporter for the first 10 years of my career. I wrote for newspapers and websites and stuff. It was when I got to make Slow Burn that I experienced the power of audio. I would say the things I like about it now are still the same things that I loved about it when I first started, which is A) the ability to have people's voices and letting your listeners hear them is almost like a cheat code. Like, a person's voice, a person's way of talking, just communicates so much and it just makes them real in such a potent way. You have to really work much harder at that, I think, when you're writing for print.
So that's one. And then the other one is that, speaking of attention, people have time for podcasts in a way they don't have as much time for long magazine pieces and books these days, right? I remember when I made Slow Burn, I had been writing for Slate and there were a couple of stories that I wrote that I really put a ton of work into, like 6,000-word stories or whatever. And I'd see in the backend of the Slate publishing platform, we could see how many people were reading them and for how long. I remember it was considered a win that my 6,000-word story had an "average engaged time" of like, four minutes or something. Because that meant that some people were getting to the end. And then you put out a podcast, it's eight hours long and people are hitting “next” on every episode and they want to hear the rest.
So, somehow, we have room in our lives, in our brains, to really commit to audio stories. Growing up, especially coming out of college I was imagining what success would be like as a journalist, what success would look like as a journalist, and for me it was writing New Yorker stories, writing Atlantic stories, spending six months on a piece that people would really spend time with. That became a harder and harder career to achieve, just because of various conditions in the media business. And podcasting, for me, was sort of like the life raft. It's like "Okay. That thing that I wanted, I can get it from podcasts." That's what I love about it. I think we can more reasonably expect people to stick with something, even if it's eight hours long. I don't think this new show's eight hours long, I think it's like six hours long. But that's still a long time.
KJ: Absolutely.
LN: And our completion rates that I hear about are really good, which suggests that people are sticking with it.
KJ: Your career has evolved a lot, but what do you see as the through line of your work overall, and what kind of keeps you engaged?
LN: I think what keeps me engaged is just choosing stories where I don't really know what I think about them or stories where I have a bias that I can identify but that am trying to unpack and push back against. It's not so interesting to do a story where you know the conclusion before you start. To me, the pleasures of journalism, the pleasures of sitting with someone for two hours and interviewing them, is that you don't know what they're going to say. I've never set out to make a show to prove a point. What we really look for, all of us who work at Prologue and who work on these shows, we want the shows to sound like people thinking through something rather than delivering a polemic. We want listeners to be buffeted from thinking something is really obvious to thinking that the opposite is just as obvious.
"I think more than you'd expect, some of the most consequential changes to our society have been the result of just a couple people making choices. I think that lends itself well to a character-driven approach to history."
I always go back to this one example of this, which was in the . We had an episode about this controversy over bathhouses in San Francisco where it became clear at a certain point that the people were getting AIDS in these places—gay bathhouses—where people would come and have sex and clearly there were a lot of infections happening. So, there were people who said, "We’ve got to shut these places down." I remember thinking at the beginning and, I think, listeners who listened to that episode would conclude that, "Yeah. Those people were right. Gotta shut down these bathhouses, they're responsible for so much spread of this disease." And then you hear the counter-argument from the people who were fighting just as hard to keep these bathhouses open. You hear about how these bathhouses were so important for gay liberation. They were the only place where people could feel free. And the slippery slope of closing bathhouses to limit transmission could lead to other rollbacks of LGBT rights. Suddenly maybe there's no gay bars. Maybe suddenly you can’t have gay sex at all. And so you hear that and you're like, "Oh, it's not as obvious as I thought."
That is the feeling we are always chasing. It's like rendering complexity in its most kind of visceral form. It's not to say we don't have a point of view. I think we definitely do, we certainly wouldn't claim to be objective journalists who are just stating facts that people can come to their own conclusions about. We're definitely interested in interpretation and argumentation. But we do want people to come to their own conclusions. It's been really interesting with every show we've put out to see how different people react because often they'll come to totally different conclusions about what they think, and that's really rewarding.
KJ: Well, I can't wait to hear what our listeners think. This is a topic that so many people are interested in. I'm really thrilled you guys covered this and that you could be here today to talk to us. Thank you so much for being here.
LN: Thank you, Kat. This was so fun. I really appreciate it.
KJ: Listeners, Backfired: Attention Deficit by Leon Neyfakh and Arielle Pardes is available now on Audible.