Are we Overmedicating Schoolchildren

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Many parents and educator are concerned that too many children and adolescents with ADHD are taking medication to treat the disorder.

What are parents' treatment options?

What does your research have you to think is the most effective approach to managing the symptoms of ADHD in preschool, school or school age students?

Support your reasoning with information from the professional literature.

Introduction:

My position on this topic is taken from the point-of-view of a parent; a teacher and a victim of this under-diagnosed, yet over-publicized Emotional/Psychological phenomenon known as Attention Deficit Hyperactivity Disorder or Attention Deficit Disorder (ADHD/ADD) and I have stories from each perspective.

The position taken by this author regarding the issue is one of frustration and ambivalence - ambivalence because the frequency and popularity of the ADHD/ADD diagnosis by family physicians, pediatricians, school psychologists and parents of school aged children is justified and deserved because the disability DOES exist and shouldn't be denied. But, the frequent premature or immediate reaction by school teachers to assume that a rambunctious ("unruly - noisy, very active, and hard to control, usually as a result of excitement or youthful energy" - MS Word Encarta Dictionary [my underline] ;) student, (usually male) as an ADHD disabled learner is becoming a blanket reaction used by teachers possibly trying to explain inadequate classroom management, and that frustrates me.

Now my future colleagues in the education profession may be offended by this interpretation, but I have observed the occurrence and heard the comments time and again as I have assisted and substitute taught in classrooms across Fairfield County, CT. My position is that this assumption must not be the haven of first resort by teachers seeking refuge from rowdy, boisterous youngsters they can't reign-in. The need for teacher-centered firm and stern guidance is something that may be unpopular with "cooperative-learning" proponents, but as you set your classroom tone in September, it will pay off with effective and constructive student-led instruction in June.

Now of course I must acquiesce and rationalize for the sake of pragmatic dialog -- the ADHD disability is definitely real. I have lived with it for 54 years and believe me, it can drag a victim into a mire of disorganization, depression and fog from which he or she believes they never will recover.

To be a student struggling with this disability in 1971 is something not to be wished on anyone, but that was then…today there are so many therapeutic resources that we must continue to make available for students that are truly lost in their own minds. But the "pendulum may have swung too far" with the prevalence of diagnoses and subsequent prescription of psychotropic medications; this is something worthy of discussion.

The following Position Paper will provide the reader with numerous perspectives, both my own and those of professionals much better qualified to interpret this position having numerous letters after their last names. And this paper also portrays my enthusiasm for the topic because of its affect on my performance (or lack thereof) as a student. So this is my position in which I believe strongly because this Learning Disability is one that needs a better definition, a better presentation, a better reputation, a better treatment and a better understanding…particularly among teachers.

["Paul, your writing is too pedantic" …"Pedantic:" =

"Too concerned with what are thought to be correct rules and details, e.g. in language" (MS Word Encarta Dictionary.)

"Characterized by a narrow, often ostentatious concern for book learning and formal rules: a pedantic attention to details." (Free Online Dictionary)

"1. Ostentatious in one's learning. 2. Overly concerned with minute details or formalisms, esp. in teaching." (Dictionary.com)]

Too wordy; caught up in using excessive erudite text to impress the reader; verbose.]

While this is a lame attempt at humor, it's demonstrative of an ADHD symptom - the overwhelming need to research and include as much content as possible in a verbose attempt to overcompensate for disorganized processing: "sorting out what information is relevant for the task at hand" (Smith, M.A., & Block, M.A., 2010)

Parent of an ADHD Child

As a parent, I watched as my wife took exception with a Preschool Teacher telling her that her precious 4 yr old son was exhibiting traits indicative for a child w/ADHD -- yet three or four years later I also recall our begging his Elementary School administrators to allow him to be tested and treated in the Special Education program because of an obvious LD condition due to this attention disability. And the story continues - of a parent dealing with Psychologists testing; Pediatricians medicating; School nurses bureaucratizing; Special Education teachers & class teachers' bickering - all while our son was struggling trying to learn. This was part of the adventure we endured leading up to and after he had been diagnosed in the 3rd grade with ADHD and some behavioral concerns.

However let's step back and look at the larger picture - where does any parent of a struggling child even begin to sort out their options trying to find solutions to a perceived attention disabled child?

The research and ADHD parent community found on the internet mostly recommend that a child's pediatrician or family doctor is a good place to start so that he/she can rule out many other physiological or emotional causes for a child's inability to focus, stay on task or other passing behaviors that seem like ADHD. It also enables the medical doctor an opportunity to asses the family and the child's role in that family. But this is often just the beginning; the family physician can provide a recommendation to the school psychologist or another specialist for the child to be tested to evaluate their cognitive abilities. But it is also important for parents to understand that ADHD diagnosis isn't as simple as taking a temperature or peering down a child's throat: "No single test can diagnose a child as having ADHD. Instead, a licensed health professional needs to gather information about the child, and his or her behavior and environment." (Health and Human Services, NIMH. 2008)

The panel of tests and studies needed to provide a complete (and often legally required) ADD/ADHD diagnosis may be financially burdensome. However, the methods available to parents have evolved rapidly over the past ten years so that school districts and their professional health staff can better assist parents with obtaining and/or providing a diagnosis from a licensed health professional. A rare "glitch" in this process is when a school district won't perform the testing as a result of a pre-referral review. This is where the financial wherewithal of families trying to ensure a definitive understanding of their child's disability is important and unfortunately sometimes lacking.

When schools assist or provide testing those results may occasionally result in a diagnosis with which parents do not agree or find the school district's recommendation insufficient for what they believe is accurate, and the testing necessary to provide a "second opinion" may be costly to alter the findings. However beginning in 1990 through today the Federal government in their recent redefinitions of ADHD under the Individuals with Disabilities Education Act (IDEA) has also reclassified funding categories available for children with ADHD to include Supplemental Security Income, (SSI).

The turmoil that has ensued for families trying to pay for even an initial diagnosis or treatment for a child suspected of having an attention deficit condition has made the political aspects of the affliction even more confusing:

"In 1990, a Supreme Court ruling led to the modification of the Supplemental Security Income (SSI) program-which provides financial assistance for the disabled-to include low income children diagnosed with ADHD. Policymakers later rescinded this expansion and many children with ADHD were cut from the SSI program in the latter half of the 1990s, but in the first half of that decade rates of new children enrolling in the program with a qualifying diagnosis of ADHD increased almost threefold." (Medicating Kids, 2008)

So the options available for parents trying deal with a suspected ADHD condition have evolved both in the category of diagnostic resources but also in financial resources available to help them support those efforts. Since that time in the early 1990's and the passage and expansion of IDEA legislation to include ADHD the options available for parents of any Socioeconomic Status (SES) have become a much broader spectrum.

There is however a larger portion of this process to be discussed as we move forward - when the diagnosis from a psychologist or other health professional includes a recommendation for the child to receive psychotropic medication to treat the ADD/ADHD condition. Because these are very powerful narcotics and depending on numerous metabolic and other factors, they affect different patients in different ways; so now parents' options to be considered have escalated to studying pharmacology and appropriate medicines and dosage for their child.

A Teacher of an ADHD Child

As a (substitute - hopefully future CT certified) teacher dealing with today's Middle School students and their daily grind, I have found the normalcy of their chaotic day and the responsibilities they face as something I not only enjoy, but in which I frequently thrive. I understand the 13 year olds that scramble to their locker to load their backpack and get on their bus, in their favorite seat, next to their BFF or sports teammate…only to remember as they jump off the bus in their driveway that they forgot their algebra notebook for that day's homework assignment…This child is one that I see in the Nurses office at lunch daily getting his/her ADHD medication, or whom I know as an IEP student because of subtle marks or clues in their teacher's rosters or paperwork. I know them and they know me - we understand each other and what their responsibility is and what is mine. Unfortunately we both know what it is like to have to compensate for that forgetfulness, impulsivity and distraction among myriad other symptoms students challenged with ADD/ADHD face.

Teaching in a classroom filled with 23 or more seventh graders can be trying for any adult, whether trained as an educator or not; for a teacher to also have one or more students with an attention deficit or attention deficit hyperactivity condition, can be overwhelming. This leads to the question of whether the 7th grade students in classrooms 10, 20 or 30 years ago may have had an ADD/ADHD condition, and if they did, how did teachers succeed with them? Of course the condition did exist and was described as far back as 1798 when Sir Alexander Crichton described the symptoms of ADHD as "mental restlessness." Then in 1845 Dr. Heinrich Hoffman described ADHD in his now famous children's poem, "The Story of Fidgety Philip," which accurately described a child with attention deficit hyperactivity disorder. Next in 1902, Sir George Still wrote the first clinical description of the disorder in a series of papers about children who displayed impulsivity and behavior problems. Sir George reported to a relieved parental population that these symptoms were caused by a genetic dysfunction and not by poor parenting. Since then, a wealth of research on the symptoms, causes, and treatments for ADHD have been published. And it has been defined under numerous headings and always seems to come back to the one institutional setting where it is most evident - the classroom.

In the introduction of school psychologist Dr. Jim Wright's text: "Attention-Deficit Hyperactivity Disorder: A School-Based Evaluation Manual" for the City of Syracuse, NY he explains that ADD/ADHD arrived at its zenith in the late 1990's because of where it was most prevalently observed:

"Despite the fact that children with ADHD form only a small minority of all students, they frequently come to the attention of their teachers because they display a high degree of externalizing behaviors (i.e., off-task behaviors that are easily observed, may distract other students, and can be disruptive to the functioning of the classroom). In fact, because the symptoms associated with attentional disorders appear to be most apparent and problematic in educational settings, ADHD has even been defined as "a school-based disorder" (Atkins & Pelham, 1991; p. 202). Consequently, students with ADHD are also quite regularly brought to the attention of the school psychologist and other members of a building child study team by concerned teachers or parents, who in addition to concerns about these children's disruptive behaviors may note academic underperformance, disorganization, and social-skill deficits."

Because of the frequency of this observable (mis-)behavior and academic challenges faced by students (and teachers) in the classroom Dr. Wright and medical and psychological professionals around the country debated who was to be the authority on diagnosing and treating ADHD; unfortunately this wrangling occurred while communities were swamped with media driven rumor, anxious parents worried about Johnny or Susie's falling grades and younger and possibly ill trained teachers arrived in classrooms needing effective management.

The restless public has somewhat subsided in the mid to later 2000's with a clearer definition of diagnostic criteria put into the IDEA as well as in DSM-IV and with the need for schools and school boards to meet these mandated standards with more effective diversified teaching methods. But that doesn't mean there still aren't teachers who need a better understanding of why that wisecracking male student has a Special Ed "pull-out" just when he/she has him "buckled down." It also means that those contemporary teachers who want to be "all they can be" by conducting cooperative learning activities such as skits, performances or other multimedia student-led lessons need to realize that 1) that rambunctious student in their class may not have a ADD/ADHD condition, they are only acting out the way "normal" 13 year olds do; and 2) if they do have such a condition, by merely medicating their behavior problem doesn't absolve the teacher from the responsibility of managing their classroom effectively.

A Victim of ADHD

As a victim of this disability I recall the days in the 1960s of my father's deep voice yelling at me that "you have the potential, why can't you just 'buckle-down' and do the work!" and the feeling of failure because I didn't know what was causing me to not care and why, when I was being yelled at, was I so worried about the mess in my room, instead of listening to what Dad was saying, and why won't he just sign the damn report card and leave me alone while I pretend to do my homework and instead just play with the crap on my desk. And I know how difficult it is to be told by a tyrannical corporate supervisor that the "little details in this job are what are going to bring you down" and being put on probation because of missing too many commas, semicolons and spelling errors!

The condition in my life from 1956 until the early 1980s didn't really have a name it was just that I was easily distracted and needed to stay more focused and more organized. So, even before it had a name, one developed compensation techniques for the harmfully frustrating traits of the ADD/ADHD condition… Setting triple alarms to not miss a class; asking Mom or Dad to knock on my door to make sure I got up for practice; putting items purposely out-of-place on the floor as a reminder…but of what? I am still setting kitchen timers to remember to pick someone up at school, the train, the car repair, or just turn off the oven.

It isn't the task that is the challenge; it is avoiding the multitude of other distractions and thoughts that cloud your memory and frustrate you when that "spinning plate" or "juggled" task falls and you've let someone down, frequently yourself.

The responsibilities of a teacher are extensive and two of the critical tasks to be borne are to stay organized and manage your classroom. This means that the methods for compensation for any disability must be balanced between those that are one's own and those provided by an external structure. An effective teacher utilizes all of the techniques, training and opportunities they may find available, but he or she shouldn't rely on a pharmaceutical treatment as a substitute for clear concise and consistent classroom management.

Rationale

Supporting Reason #1

Obviously I am not a big proponent of medicating young children -- the solution to life's problems, particularly for a child who has yet to learn personal fortitude or self-assuredness is something that "can't be found in a pill" is a life learning lesson that MUST be reinforced as the treatment and assistance is provided.

This isn't to say that I don't understand the problem we all face trying to "learn how to learn" from Elementary School through College and even in a young professional's career. It is the simplicity that bothers me - the perception among students that if I don't do my schoolwork it's OK because I am a disabled learner. The idea that students with ADHD can use accommodations such as extra time and medication to "get by" the system is something that needs not only to be avoided, but to be communicated as NOT acceptable for students receiving treatment;

The prevalence of ADHD/ADD diagnoses (increased 30% - 60% since 1990 [1] ) has demonstrated that there a lot of parents and therapists that may be finding their children to be struggling with academic challenge;

Alternatives or supplemental strategies for treatment MUST also be included with a medication for treatment and assistance with this disability. While some opponents or people who deny the existence of ADHD have stated that students just need a "swift kick" (i.e., "buckle down") the existence of the disability has been well documented and proven that medication in addition to other methods will make ADHD a manageable and lifestyle inhibitor but much less of a disabler. [2] 

Supporting Reason #2: A parent and family's responsibility to an individual with ADHD never really ends - a teacher has a student for 1 year and with the extra effort necessary - they can manage this child to becoming an effective learner.

When a child or young adult is diagnosed with the Attention Deficit Disorder there often are two responses from family members - "oh no, now we have to deal with this" OR "well that's a relief now we can get them some help."

A person with ADHD usually must try to understand what methods they may employ for their own treatment and add these to the many strategies they have employed for compensating for an inability to function or perform in so many areas.

Teachers who are intolerant of students with ADHD are often those who are most frustrated with systems, bureaucracy and mundane aspects of their job. And to them that is what they're doing - "a job," not a "calling," not a "disposition," not a "vocation;" they aren't vested in their students' success they are there for a paycheck. And most likely they're counting the days until June's Summer break….these are the teachers that need to realize - compared to today's corporate world what they're doing each day isn't a job, it's a picnic and the students they have with ADHD aren't going to go away.

Supporting Reason 3: A student with ADHD isn't someone that needs extra sympathy or special recognition, in fact they often want just the opposite - to be quietly encouraged and treated like any other student

All kinds of stories have appeared in media and other forums where people believe that ADHD is such an debilitating condition that it gives parents an added responsibility and trial to endure as they raise and cajole their "labeled" child through school. This is not only false but it is totally contrary to an effective method of raising a child with ADHD - I know I have.

My son is now a second year student in college. I have coached and led him through numerous trials and hurdles. And more often than not, he has performed above expectations, usually because of a sense of personal pride and positive self image.

Treatment for students with ADHD is an evolving and improving field. More and more professionals in numerous medical, social, political and other disciplines are expanding the types and techniques for treatment. "This is an exciting time in ADHD research. The expansion of knowledge in genetics, brain imaging, and behavioral research is leading to better understanding of the causes of the disorder, how to prevent it, and how to develop more effective treatments for all age groups." [3] 

Conclusion

A balance of treatment and recognition; management and motivation; policies and tolerance are what is needed now more than ever with regard to students struggling with ADHD. This, combined with improved communication and media awareness by professional societies and parental networking groups, is a major portion of this balancing effort.

It isn't that medication is too prevalent; it is just a symptom of the misreporting and misperception that parents are overmedicating their children.

The ongoing education of children with ADHD from preschool through college is improving daily, however the communication of those treatments and portrayal of lazy students is something that must be addressed before society will accept and encourage parents to make their disabled learner become the successful well-rounded individuals they may and should become.

Classroom teachers are now facing more challenges than ever before, from parents, communities and government authorities. Their students shouldn't represent an additional challenge because of inadequate classroom management or labels on disabled learners. The effective teacher is aware of their role in balancing effective teaching with efficient learning all while managing a quality classroom.

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