ADHD: Still more questions than answers about how to treat it

The label ADHD trivializes the disorder, asserts Russell Barkley, a neuropsychiatrist and professor of psychiatry and pediatrics at the Medical University of South Carolina who has published more than 300 peer-reviewed articles on the condition.

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“ADHD is not simply about not being able to pay attention. Describing it as such is like calling autism a ‘not looking at people’ problem,” he said, and there is much more to ADHD.

Some practitioners and researchers say drugs are by far the most effective treatment. Others argue that long-term drug use addresses symptoms only and does not provide important tools to help people manage their inattentiveness. They say it’s more helpful to focus on behavioral interventions, nutrition, exercise and special accommodations at school.

The American Psychiatric Association says there is no doubt that ADHD exists — and it estimates that 5 percent of U.S. children have the condition.

The Centers for Disease Control and Prevention puts the figure higher, reporting that 11 percent of U.S. children age 4 to 17 had been diagnosed with ADHD as of 2011.

Whatever the number, many parents of kids with attention problems struggle with how best to help them. They seek guidance on whether to medicate. They want to know how to advocate for them in school and with their doctors. They look for ways to help them grow into well-adjusted, successful adults.

Science recognizes ADHD as involving brain development, although there is disagreement over what exactly happens in the brain to trigger ADHD symptoms. Barkley says there is an inherited aspect, though he also says the condition is sometimes triggered by environmental factors such as exposure to smoke and alcohol before birth. ADHD impairs self-regulation of behavior and emotions. And it impairs regulation of thoughts involving planning, organizing and problem-solving, he said.

Research shows that the maturation of brain regions associated with these functions is delayed by about three years in people with ADHD. Studies also suggest that these regions are smaller than normal and that they are less active. Also, imaging tests show dysfunctions in the networks of nerve cell fibers that allow brain regions to communicate with one another.

“Some of these networks affect working memory, which allows us to retain information. This explains the forgetfulness and difficulty completing tasks,” Barkley says. “A network tied to timing of our actions explains why these people are chronically late. A network tied to impulse control explains why they have five times more speeding tickets and why their relationships often head south. A network affecting ability to sustain attention is why they, for instance, have three times more car accidents.”

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Whether children should be treated with medication sets off debate. “Some families say medications changed their child’s life for the better; others tell you horror stories,” said Ruth Hughes, former chief executive of Children and Adults with Attention-Deficit/Hyperactivity Disorder.

Advocacy groups such as CHADD suggest a mixed approach that may include medication but also entails the application of parenting skills, behavioral interventions and school support.

Studies have produced contradictory results on the effectiveness and safety of medications for ADHD. A 2014 article in the Journal of Health Economics, based on a 14-year study involving 8,643 children with ADHD, concluded that “expanding medication . . . had little positive benefit and may have had harmful effects, given the average way these drugs are used in the community.” Yet a 2014 meta-analysis of 25 studies concluded, “Short-term [drug] treatment is safe and superior to placebo for ADHD symptoms and secondary outcomes.”

Hughes says parents should decide with their children’s doctors whether to use medication; for additional advice, she recommends “ADHD: Parents Medication Guide,” a booklet prepared by the American Academy of Child and Adolescent Psychiatry and American Psychiatric Association.

“It’s based on science, but it’s not all about ‘Yes, medicate your kid,’ ” Hughes said. “It takes a thoughtful approach.”

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Hope Scott, a developmental pediatrician in Reston, Va., prescribes medication to most of her ADHD patients. But drugs are only one part of the plan.

“Medications improve distractibility,” Scott said. “But they do not touch development of time management or organizational skills. They help you focus on cleaning your room, but you still need to learn how to do it.”

To teach such skills, she suggests ongoing behavior management measures such as reward tokens redeemable for such things as sleepovers with friends. Scott also recommends educational support, including classroom accommodations, such as more time to take tests or working on homework assignments during school hours for students who can’t focus after a full day of school.

Nitya Ramachandran, an Olney, Md., integrative pediatrician focusing on nutrition and other complementary and alternative medical protocols, has parents keep a diary noting what their children eat and when their symptoms worsen. Some studies, including a recent one in European Child Adolescent Psychiatry, suggest that food additives provoke ADHD behaviors, though the National Institutes of Health reports only a small percentage of children improve by restricting these additives.

“From the diaries and what parents tell me, many kids find it harder to focus, are tired or hyper when they eat processed foods and, in some cases, food additives like artificial dyes,” Ramachandran said.

Sometimes symptoms subside when these ingredients are eliminated. Ramachandran prescribes fish oil and probiotics to promote nutrient absorption. She checks thyroid hormones, vitamin D and iron levels — studies suggest deficiencies in these areas may be associated with ADHD — and emphasizes the importance of sleep.

Nearly 70 percent of her patients take low-dose medication; about half are weaned off them once they can focus on academics and their stress levels subside — usually within several months.

“They do well,” she said. “But they follow this integrative approach looking at overall health.”

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ADHD is hard to diagnose because there are usually coexisting conditions with related symptoms, such as obsessive-compulsive disorder or learning disabilities including dyslexia, said Barry Ekdom, a Fairfax, Va., neuropsychologist. Like many neuropsychologists, he assesses for ADHD by taking the patient’s history and testing several functions such as memory retrieval, which in some cases may be an indicator of ADHD and or other cognitive problems.

“People with ADHD get it when they study, but they blow the test — that is memory retrieval. The knowledge is learned and remembered. But they can’t retrieve it when questioned,” Ekdom said.

He suggests having ADHD children practice accessing information, such as repeatedly answering review questions before a test rather than simply reading material to be covered.

Auditory and visual cues — such as to-do lists and recorded messages — can help, some experts say.

Cary Euwer, a 29-year-old from Chevy Chase, Md., did well in high school, dealing with ADHD by studying late into the night and getting up early. The increased demands of college were too much for him. He lacked organizational skills and he couldn’t focus.

A turning point came when he took a college class where he was helping fourth-graders with science, a subject he loved but struggled with. “The way I was taught was too abstract for me. But I got to do hands-on work with these kids, which was more concrete and made it easier.”

Euwer also worked with a coach from the Edge Foundation, a national nonprofit that offers assistance to people with ADHD. “We focused on organization strategies like breaking tasks in small steps. We worked on time management, to help me think about how long something would take and planning ahead.” Taking breaks and exercising were also tremendously helpful.

The coaching, he said, helped him learn how his mind worked. Now he is completing a graduate program at Maryland Institute College of Art in Baltimore, focused on developing design concepts (such as communications tools) to address social problems.

“Once I had skills,” he said, “it was okay that I have a million thoughts coming at me at once.”

Hillary Clinton calls for sweeping expansion of voter access

In a speech at a historically black college here, Clinton called for federal legislation that would automatically register Americans to vote at age 18 and would mandate at least 20 days of early voting ahead of election days in all states.

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Making her most fiercely partisan political speech since her first, failed run for president in 2008, Clinton attacked Republicans for what she characterized as a calculated attempt to turn back the clock on voting rights — and called out several potential 2016 opponents by name for backing voter restrictions as governors.

“Today Republicans are systematically and deliberately trying to stop millions of American citizens from voting,” Clinton said during a speech at Texas Southern University. “What part of democracy are they afraid of?”

The pointed attacks and sweeping policy proposals signal that Clinton intends to make voter access a major plank in her campaign platform — a move aimed at firing up the Democratic base and portraying her GOP opponents as suppressing votes. Her campaign’s top lawyer, Marc Elias, has co-filed lawsuits over voting access in Ohio and Wisconsin — both key presidential battleground states with Republican governors who may join the 2016 race.

The Republican National Committee accused Clinton of being “misleading and divisive” and noted that her home state of New York does not provide early voting. “Her exploitation of this issue only underscores why voters find her dishonest and untrustworthy,” RNC spokesman Orlando Watson said in a statement.

During her speech, Clinton said Republican state legislatures are intentionally restricting voting by curtailing early access to the polls and other measures in an effort to suppress Democratic turnout. Among the potential opponents she singled out for criticism were New Jersey Gov. Chris Christie; Wisconsin Gov. Scott Walker; former Florida Gov. Jeb Bush; and former Texas Gov. Rick Perry, who announced his own second run for the White House on Thursday.

“Today there are people who offer themselves to be leaders whose actions have undercut this fundamental American principle” of a free vote, Clinton said.

Perry spokesman Travis Considine said Clinton’s remarks demonstrate “how truly out of touch she is with the people of Texas.”

“While it is unfortunate, Gov. Perry is not surprised that Hillary Clinton would come to Texas and call for weakening the integrity of our election process,” Considine said in a statement.

Nationwide mandatory voter registration would generally help Democrats, whose support frequently comes from younger, poorer and minority groups that may also be less likely to sign up to vote at 18 on their own. That change and a mandatory minimum period for early voting would have to be approved by Congress — now controlled by Republicans — so it is unlikely to happen in time to benefit Clinton in the 2016 election if she is the Democratic nominee.

“None of them will come easily,” she acknowledged in her speech.

Clinton also alleged that Republican efforts to limit voter registration have a disproportionate impact on “people of color, poor people and young people from one end of our country to the other.”

Under universal voter registration, every citizen would be automatically registered to vote on their 18th birthdays, unless they actively opt out.

About 71 percent of eligible adults nationwide are registered to vote, according to census figures, and a lower percentage actually show up at the polls. Registration and turnout tend to be higher among older and relatively affluent white voters, who are also more likely to vote Republican.

The requirement for in-person early voting that Clinton seeks would also mandate that polling places have weekend and evening hours.

Although early voting has become fairly common in the past decade, many Republicans say it increases the opportunity for fraudulent voting. Republicans have raised similar objections to same-day registration and other efforts — many of them led by Democrats — to make voting easier or more convenient. Clinton dismissed such complaints as unfounded.

Election analysts generally agree that voter fraud is rare, although there have been a handful of well-publicized examples of fraudulent names being added to the rolls.

Clinton’s address comes as Democrats are pursuing legal challenges to voting rule changes approved by Republican legislatures in several states.

“This is, I think, a moment when we should be expanding the franchise,” Clinton campaign chairman John Podesta said in an interview Wednesday. “What we see in state after state is this effort by conservatives to restrict the right to vote.”

In recent weeks, Elias has co-filed lawsuits over voting access in Ohio and Wisconsin — both key presidential battleground states with Republican governors who may join the 2016 race.

“This lawsuit concerns the most fundamental of rights guaranteed citizens in our representative democracy — the right to vote,” the lawyers wrote in a federal complaint filed Friday in Wisconsin.

Walker spokeswoman Kirsten Kukowski said voter access restrictions make it “easier to vote and harder to cheat” and added, “This is a bipartisan issue and Hillary Clinton and the Democrats are on the wrong side.”

Since the 2010 Republican wave, 21 states have implemented new laws restricting voting access, some cutting back on early voting hours and others limiting the number of documents considered valid identification to vote, according to a new analysis from the Brennan Center for Justice, a nonpartisan think tank at the New York University School of Law. For 14 of those states, the 2016 contest will be the first presidential election with the new restrictions in place.

Some limits also flowed from the 2013 Supreme Court decision that invalidated some parts of the Voting Rights Act of 1965. The day that decision came down, Perry praised it as a “clear victory for federalism and the states” and vowed to proceed with the implementation of a strict photo ID requirement, previously blocked under the law. That requirement is currently being challenged in court, with a resolution expected as soon as this summer.

About three dozen states and the District offer early voting of some kind, allowing voters to cast ballots before Election Day without an excuse. The average early voting period is roughly 22 days, the bipartisan National Conference of State Legislatures reported earlier this year.

Oregon’s breakthrough “new motor voter” law passed earlier this year is the closest any state has come to the kind of automatic registration endorsed by Clinton. She praised Oregon as a leader in modernizing antiquated voting procedures, including paper registration.

Under the new law, all Oregonians applying for a new or updated driver’s license are automatically added to the voter rolls, unless they opt out. The state has estimated that the law will add about 300,000 voters to the rolls.

Younger voters are the least likely to be registered and have tilted toward Democrats in recent years. In 2012, the Census Bureau reported 57 percent of citizens under 30 were registered to vote, compared with 78 percent of those 55 and older. Voters under 30 supported Barack Obama by a 29 percentage-point margin over Mitt Romney, according to network exit polls (66 percent to 37 percent).

In 2008 and 2012, African-American turnout rates surged to match or exceed turnout among whites for the first time, but a central question in 2016 is whether blacks will turn out at similar levels when President Obama is not on the ballot.

Hispanics and Asians — groups Obama won by wide margins as well — vote at far lower rates than whites and African-Americans, representing a large untapped pool of Democratic support. Automatic registration among these groups may encourage more voting participation.

Exit polls in 2012 found that Obama racked up a seven-point lead over Republican Mitt Romney among early voters, compared with a one-point edge among those casting ballots on Election Day.

Democrats’ advantage among early voters was less clear according to voter registration data tracked by the U.S. Elections Project. In five of seven states where data are available, Democrats made up about the same percentage of early voters as they did on Election Day.

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Chokshi reported from Washington. Scott Clement contributed to this report.

NATO maneuvers to keep cool war with Russia from becoming hot

Defense Secretary Ashton Carter, in the midst of a week-long trip to Europe, is reassuring nervous allies that the trans-Atlantic alliance would ride to the rescue if Russia attacked.

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The three tiny Baltic nations, Russia’s neighbors and parts of the former Soviet Union before they joined the North Atlantic Treaty Organization in 2004, are especially anxious.

“We have reasons to believe that Russia views the Baltic region as one of NATO’s most vulnerable areas, a place where NATO’s resolve can be tested,” said Sven Mikser, Estonia’s defense minister.

On Tuesday, Carter tried to meet the test, saying that the United States is moving about 250 tanks, howitzers and Bradley Fighting Vehicles to Estonia, population 1.3 million, and five other alliance nations as a show of force.

“While we don’t seek a cold war, let alone a hot war, with Russia, we will defend our allies,” he told reporters in Tallinn, the Estonian capital.

Still, the U.S. defense chief confronts doubts about both NATO’s capability and its willingness to act. His campaign of deterrence, while reminiscent of the Cold War, is playing out on a vastly different political, military and economic landscape.

The Cold War’s tidy us-versus-them face-off has been replaced by a web of commercial and cooperative ties among Russia, the United States and European nations. Russia provides almost a third of the European Union’s natural gas needs and is Europe’s third-largest trading partner.

Those ties have contributed to doubts about NATO’s willingness to fight for its newest members. Majorities of the public in Germany, France and Italy oppose defending NATO allies on Russia’s periphery if they come under attack, according to a June 10 Pew Research Center survey.

“Nobody’s going to war with Russia over Estonia,” said Leon Aron, a Russia specialist at the American Enterprise Institute in Washington.

Doubts about NATO’s will to act are matched by concerns about its ability to fight. The alliance is fielding a new rapid reaction force that’s intended to reach trouble spots within 48 hours — far faster than the minimum 30 days needed before the Ukraine crisis.

Even that quicker tempo, however, may not be fast enough. A repeat of the murky circumstances that governed the opening phase of the Ukraine crisis — operations by armed units with no insignia, coupled with stage-managed pleas for help by local ethnic Russians — could present NATO with a difficult choice.

Carter said allied officials later this week will discuss ways to ensure that the “speed of decision-making” matches military needs.

That hasn’t always been the case. In 2003, it took a month after a U.S. request to NATO for Patriot air defense missile batteries to arrive in Turkey.

“It’s pretty clear they would not be there in time,” said Terrence Kelly of the Rand Corp., a nonprofit policy research organization, who’s participated in Baltic war games. “Our research clearly indicates that Russia could get to the Baltic Sea very, very quickly.”

Some doubt that the Russian threat will materialize. Ukraine, with a special, emotional importance to Russian culture, wasn’t a member of NATO, and the deep reservoir of public support from ethnic Russians in Crimea would be difficult to replicate in Estonia, Latvia or Lithuania.

“The Russian speakers in these countries have been living in the West for a long time,” said Sean Kay, a former Defense Department consultant and director of the international studies program at Ohio Wesleyan University. “It’s not the Donbass,” he said, referring to the disputed eastern region of Ukraine. “They’re citizens of the European Union.”

U.S. officials see the Russian leader’s support for pro- Russian separatists in Ukraine as only part of a broader campaign to split the Western alliance — what Rand analysts labeled a “cool war” in a March 25 study.

“Weakening, if not destroying NATO, is one of Putin’s key national security objectives,” said Kelly, director of the strategy, doctrine and resources program for the Rand Arroyo Center, funded by the U.S. Army.

Prepositioning equipment for one armored combat brigade spread among Estonia, Latvia, Lithuania, Bulgaria, Romania and Poland — the allies closest to Russian soil — is intended as a signal to Putin.

No one expects Russian armored formations and thousands of soldiers to pour across the borders. The fear is a repeat of the deft propaganda and irregular militias that Russia has employed to devastating effect in eastern Ukraine.

Or Russia could launch an offensive across virtual borders using cybertools that didn’t exist in the Cold War. In 2007, during a dispute between Estonia and Russia over the relocation of a Soviet war memorial from the center of Tallinn, “denial of service attacks” crashed Estonian government websites.

Carter on Tuesday toured an Estonian cybersecurity research center housed in a handsome stone building that served in the 19th century as a barracks for the Russian czar’s army.

Since Russia used such “hybrid warfare” to swallow the Crimean peninsula in March 2014, allied military forces have staged a near-continuous series of military exercises to demonstrate resolve while political leaders have vowed to counter any further Moscow moves.

“The United States and the rest of the NATO alliance are absolutely committed to defending the territorial integrity of Estonia, Latvia and Lithuania, just as we’re committed to defending all of our allies,” Carter said.

If today’s Russian threat differs from that of the Cold War, Europe’s military balance also has evolved. The U.S. remains in the midst of a long drawdown of its European forces despite the Ukraine crisis.

The U.S. has about 65,000 troops in Europe today compared with an early-1990s peak of more than 300,000. Repeated headquarters staff cuts have made U.S. European Command the smallest combatant command in the U.S. military.

In April, the U.S. Army announced the withdrawal of 24 Apache and 30 Blackhawk helicopters from Germany.

U.S. forces in Europe “have been sized over the last two decades for a Russia that we were looking to make a partner,” Air Force General Philip Breedlove, commander of U.S. European Command and Supreme Allied Commander in Europe, told the Senate Armed Services Committee in April.

Russia’s military, too, pales in comparison to its Soviet predecessor. From a 1986 peak of 4.3 million men under arms, the Russian military has shrunk to fewer than 1 million in uniform, according to a March 31, 2014, Congressional Research Service study.

Putin has launched a multiyear program to expand and modernize his military, but “mismanagement, changes in plans, corruption, manning issues, and economic constraints have complicated this restructuring,” the report concluded.

The military balance may not matter as much as perceptions in rival capitals, though. Putin already has misjudged the consequences of seizing Crimea, and and allied officials want to make sure he doesn’t miscalculate again.

“NATO collectively is far superior to Russia today,” said Mikser, the Estonian defense chief. “In global terms, Russia is no match literally to the U.S., to NATO. But here in this, our corner of the world, Putin believes he enjoys superiority, regional superiority. That makes us vulnerable.”

Over the past year, the U.S. has taken several steps to shore up its deterrent. Under the $1 billion European Reassurance Initiative, the Pentagon has increased the frequency of European exercises. It’s flown A-10 attack aircraft to bases in Romania and funded improvements to railheads and landing strips that would be needed in the event of trouble along NATO’s eastern or southern flanks.

The prepositioning of enough equipment for 5,000 soldiers announced Tuesday is a further warning. But it may not be enough.

“That will end up being an initial step,” said retired Adm. James Stavridis, a former supreme allied commander and now dean of the Fletcher School of Law and Diplomacy at Tufts University in Medford, Massachusetts. “The Baltics’ desire to have a small permanent presence of U.S. troops — companies or battalions — will continue to grow. I think we’ll end up in that position in another year or so.”

Sesame Street’s educational impact is comparable to preschool, study finds

NEW YORK — Most Americans born since the mid-1960s have a favorite “Sesame Street” skit.

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Jennifer Kotler Clarke watched hers on a black-and-white television set in her family’s Bronx apartment. There were two aliens: One of them had long arms that didn’t move, while the other had short, moving arms. The aliens wished to eat apples from a tree, and they succeeded, after a couple of minutes, by working together. “Let’s call this cooperation,” one of them says. “No,” the other replies, “let’s call it Shirley.”

Clarke grew up to be the show’s vice president for research and evaluation, and she has long believed that the program’s laughs and lessons stick with children. Now, landmark academic research appears to back her up.

The most authoritative study ever done on the impact of “Sesame Street,” to be released on Monday, finds that the famous show on public TV has delivered lasting educational benefits to millions of American children — benefits as powerful as the ones children get from going to preschool.

The paper from the University of Maryland’s Melissa Kearney and Wellesley College’s Phillip Levine finds that the show has left children more likely to stay at the appropriate grade level for their age, an effect that is particularly pronounced among boys, African Americans and children who grow up in disadvantaged areas.

After “Sesame Street” was introduced, children living in places where its broadcast could be more readily received saw a 14 percent drop in their likelihood of being behind in school. Levine and Kearney note in their paper that a wide body of previous research has found that Head Start, the pre-kindergarten program for low-income Americans, delivers a similar benefit.

The researchers also say those effects probably come from “Sesame Street’s” focus on presenting viewers with an academic curriculum, heavy on reading and math, that would appear to have helped prepare children for school.

While it might seem implausible that a TV show could have such effects, the results build on Nixon-era government studies that found big short-term benefits in watching the show, along with years of focus-group studies by the team of academic researchers who help write “Sesame Street” scripts. Several outside researchers have reviewed the study, and none are known to have questioned its results.

The new findings offer comforting news for parents who plopped their children in front of public TV every day and/or memorized entire Elmo DVDs, unwittingly.

They also raise a provocative question, at a time when many lawmakers are pushing to expand spending on early-childhood education: Do kids need preschool if a TV show works just as well?

Yes, say the economists — and the “Sesame Street” educational team. Head Start, Kearney and Levine write, was designed to provide more than an academic boost: It delivers family support, medical and dental services, and development of emotional skills that help kids in social settings.

Levine and Kearney see the study as a clear lesson in the value of a (very cheap) mass-media complement to preschool. The potentially controversial implication they embrace from the study isn’t about early-childhood education. It’s about college, and the trend toward low-cost massive open online courses, or MOOCs.

“Sesame Street,” Levine and Kearney write, was the original MOOC. “If we can do this with ‘Sesame Street’ on television, we can potentially do this with all sorts of electronic communications,” Kearney said in an interview. “It’s encouraging because it means we might be able to make real progress in ways that are affordable and scalable.”

The research can’t say whether the show continues to deliver such high benefits to children, said Diane Whitmore Schanzenbach, an economist at Northwestern University’s School of Education and Social Policy, who has read drafts of the paper and given feedback to the authors.

But, she said, it clearly shows “the importance of childhood education, which is really having its moment right now.”

The economists’ study was brought to you, so to speak, by the letters U, H and F.

“Sesame Street” debuted in 1969 with a diverse cast of humans and brightly colored fuzzy Muppets, including Oscar the Grouch, Bert and Ernie, and, of course, Big Bird. It was the country’s first explicitly educational children’s program, and it was an immediate hit: In the early 1970s, one-third of all American toddlers watched it.

That’s a Super Bowl-level audience share. But it’s even more striking because another third of the nation’s toddlers couldn’t have watched the show if they wanted to — they didn’t have the right kind of antenna to tune in to their local public television station.

This was well before the popularization of cable. TV broadcasts arrived over the air, on two different kinds of signals. The higher-quality signal was known as VHF, or Channels 1 to 13 on a standard TV set. The lower-quality signal was called UHF, and many households at that time were unable to tune it in. By a quirk of federal licensing, the public broadcasting channels in many major cities, including New York and Boston, aired on VHF channels, while others, including Los Angeles and Washington, aired on UHF.

As a result, about two-thirds of the nation’s households were able to watch “Sesame Street.” The other third weren’t.

Levine read about that divide in early 2014. He realized it was the sort of rare natural experiment that economists live for — two groups of people, divvied up by fate and the Federal Communications Commission, who could be compared over time to see whether there was a difference in their educational outcomes.

“It’s econometrically phenomenal,” he said, “because it’s essentially random, who had UHF and who had VHF.”

Levine and Kearney pinpointed which cities had high or low levels of access to the show. Then they used census data to track children from those cities throughout school, to see whether they were staying at grade level. They couldn’t study individual people, or even determine whether people in particular areas watched the show. But they found a large and statistically meaningful effect on the educational progress of children who, because of where they lived, were much more likely to be able to watch. (The effect appears to fade out before high school graduation, they also found.)

“Sesame Street” writers design their shows to have those effects.

From the start, the program rooted its scripts in an academic curriculum designed to help children — particularly low-income urban kids — prepare for school.

At first the writers focused on basics: letters, numbers, cooperation. Over the decades they expanded to incorporate research on what children needed to succeed in the classroom and in life. “We’re constantly changing the show, for good reasons,” said Rosemarie Truglio, the senior vice president of global educational content at Sesame Workshop.

When writers wanted to emphasize science learning, Truglio said in an interview in “Sesame Street” offices just off Central Park in Manhattan, they turned the inquisitive monster Super Grover into a one-Muppet embodiment of the scientific method.

When they realized that media-soaked children needed more help paying attention and controlling impulses, they decided to make an example out of Cookie Monster — the googly-eyed character who famously cannot resist sweets.

“As an educator, I was a little worried about that,” Truglio said. “Because he was going to fail, a lot.” Then she realized that was the point: Children needed to see someone struggle with the attention issues they struggle with, and try multiple techniques to overcome them. In one recent skit, modeled on the “Karate Kid” movies, Cookie Monster needs three tries to learn a special move from his sensei, but he finally masters listening with his whole body and, as a reward, he earns a cookie belt.

Which he eats.

“Sesame Street” researchers aggressively test their shows via focus groups to see what works. Their success, they said, rests on a simple formula that wraps education in entertainment, harnessing the power of human narrative. They said the approach could easily extend to college students — to MOOCs — as well as preschoolers.

“Storytelling is critical,” Clarke said. “If you organize information in storytelling, children are more likely to learn it. And adults are, too.”

Like Clarke, Kearney grew up loving “Sesame Street.” (Levine, her co-author, was of school age when the show hit the air.) Kearney remembers running through her house with her sisters, singing a Big Bird song about the alphabet. Her favorite character was the Count — the one who most resembled an economist.

Gay marriage legalized by Supreme Court in landmark ruling

Voting 5-4, the justices said states lack any legitimate reason to deprive gay couples of the freedom to marry.

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Justice Anthony Kennedy joined the court’s four Democratic appointees in the majority, bringing gay weddings to the last 14 states where they were still banned.

“The right to marry is a fundamental right inherent in the liberty of the person,” Kennedy wrote. “Couples of the same sex may not be deprived of that right and that liberty.”

The ruling is a legal landmark, on par with the 1967 Supreme Court decision that guaranteed interracial couples the freedom to wed. It punctuates a period of sweeping change in the rights of gays, coming only 11 years after Massachusetts became the first state to allow same-sex marriages.

The decision is likely to meet resistance in parts of the country and spark new legal fights. North Carolina has a new law that lets court officials refuse to officiate at same-sex marriage ceremonies. Pike County, Alabama, currently isn’t issuing marriage licenses to anyone.

In other parts of the country, same-sex marriage started almost immediately after the high court ruled. Travis County, Texas, began issuing marriage licenses to gay couples at 10:30 a.m. local time. County judges in Ohio, North Dakota, Nebraska, Michigan, Tennessee, Arkansas and Kentucky had either begun issuing licenses or stood ready to do so Friday morning, according to local news reports.

Same-sex couples in Mississippi, Louisiana and Alabama were told they will have to wait.

Chief Justice John Roberts and Justices Antonin Scalia, Clarence Thomas and Samuel Alito dissented, with each writing a separate opinion. Roberts read a summary of his dissent from the bench for the first time in his 10 years on the court.

Roberts wrote that the gay couples “make strong arguments rooted in social policy and consideration of fairness.” But, he said, “under the Constitution, judges have power to say what the law is, not what it should be.”

Justices Ruth Bader Ginsburg, Stephen Breyer, Sonia Sotomayor and Elena Kagan joined Kennedy’s opinion without adding any separate comments.

The decision comes at a time of record support among Americans for same-sex weddings. A Gallup poll conducted in May showed 60 percent favoring legalized same-sex marriage and 37 percent opposed.

“This ruling will strengthen all of our communities by offering to all loving same-sex couples the dignity of marriage across this great land,” President Barack Obama said in a statement at the White House.

Immediately after the ruling, Obama placed a call to Jim Obergefell, the Ohio man whose name will forever be attached to the ruling. Obergefell became the lead plaintiff after seeking to have his name on the death certificate of his partner of two decades, John Arthur. Obergefell and Arthur married on an airport tarmac in Maryland in 2013 just months before Arthur’s death.

“Your leadership on this issue, you know, has changed the country,” Obama told Obergefell, who was in the courtroom for Friday’s announcement.

A party-like atmosphere developed outside the court in the hours after the ruling. Gay-marriage supporters cheered, sang songs and took pictures of themselves at the site of history.

“This means finally equality for not only the entire gay community but for myself as well,” said Dan Fitzgerald, a 19- year-old gay man from Washington and student at American University.

Hundreds of companies — including Amazon杭州桑拿会所,, Google and Walt Disney — pressed the court to legalize gay marriage nationwide. They said it would help them attract able workers and simplify their employee-benefit packages throughout the nation.

The ruling “will help families across the country, make it easier for businesses to hire and keep talented people, and promote both economic growth and individual freedom,” Goldman Sachs said in a statement on its website.

The Supreme Court case involved 31 people from Ohio, Michigan, Tennessee and Kentucky. A federal appeals court had ruled against gay weddings, saying changes to marriage laws should come through the political process, not the courtroom.

Kennedy rejected that reasoning, saying the democratic process must give way to the Constitution.

“The dynamic of our constitutional system is that individuals need not await legislative action before asserting a fundamental right,” he wrote. “The nation’s courts are open to injured individuals who come to them to vindicate their own direct, personal stake in our basic charter.”

Kennedy said same-sex marriage bans violated two guarantees protected by the Constitution’s 14th Amendment: the fundamental right to marry and the right to equal protection.

Gay couples “ask for equal dignity in the eyes of the law,” Kennedy wrote. “The Constitution grants them that right.”

His 28-page opinion said marriage was an institution that had “evolved over time.”

“Changed understandings of marriage are characteristic of a nation where new dimensions of freedom become apparent to new generations, often through perspectives that begin in pleas or protests and then are considered in the political sphere and the judicial process,” he wrote.

Kennedy said people with religious objections “may continue to advocate with utmost, sincere conviction that, by divine precepts, same-sex marriage should not be condoned.”

The ruling doesn’t resolve all legal questions about gay rights. Civil-rights advocates are still trying to win anti- discrimination protections, both at the federal level and in the dozens of states where people can be fired or denied housing because of sexual orientation.

The people seeking marriage rights included Michigan residents April DeBoer and Jayne Rowse, nurses who have adopted four children, two of them with special needs. Obergefell was the lead plaintiff in the Ohio case.

The high court ruling means that “our love is equal,” Obergefell said outside the court building. “The four words etched onto the front of the Supreme Court, ‘Equal Justice Under Law,’ apply to us too.”

Roberts said supporters of gay marriage should “celebrate” the ruling and the “opportunity for a new expression of commitment to a partner.”

“But do not celebrate the Constitution,” he wrote. “It had nothing to do with it.”

Scalia and Thomas joined Roberts’s opinion and also wrote separately. Scalia called the ruling a “threat to American democracy.”

“Today’s decree says that my Ruler, and the Ruler of 320 million Americans coast-to-coast, is a majority of the nine lawyers on the Supreme Court,” Scalia wrote.

Alito said the ruling “will be used to vilify Americans who are unwilling to assent to the new orthodoxy.” He faulted the majority for equating gay-marriage bans to the laws that once barred interracial marriages.

Almost 400,000 same-sex couples have already married in places where it is legal, and an estimated 70,000 more now will wed in the new states, according to research by the UCLA School of Law’s Williams Institute.

Republicans generally expressed disappointment.

“The Supreme Court disregarded the democratically enacted will of millions of Americans by forcing states to redefine the institution of marriage,” House Speaker John Boehner of Ohio said.

“I’m very disappointed that the word of God hasn’t been upheld by #Scotus,” tweeted Rep. Walter Jones, a North Carolina Republican.

The Supreme Court had hinted at support for gay marriage in a 2013 decision that struck down part of a law denying federal benefits for same-sex spouses. At the time, only 12 states had gay marriage.

The 2013 ruling created a broad sense that the court would soon take the final step. The justices reinforced that perception by repeatedly letting pro-marriage lower court orders take effect. Those orders increased the number of states where gays could wed to 36, plus the District of Columbia, and helped acclimate Americans around the country to same-sex marriage.

_ Contributors: David McLaughlin, Billy House and Rachel Adams-Heard in Washington and Esme E. Deprez in Santa Barbara, Calif.