Friday, October 12, 2012

ADHD, Education, and Drugs

The term ADHD refers to Attention Deficit Hyperactivity Disorder. ADHD has become a commonly diagnosed condition in young children. Children so diagnosed seem to have trouble concentrating, are easily distracted, and cause disruptions or diversions in the classroom. The typical approach now is to medicate the children with amphetamines or variations on amphetamines. Amphetamines have a long history in public consciousness, having often been used to maintain alertness in dull and dreary tasks. This ability to help maintain concentration has generated some unintended uses.

A recent article by Alan Schwarz in the New York Times discussed the use of drugs prescribed for ADHD by high school students as an aid in studying for and taking tests: Risky Rise of the Good-Grade Pill. One of the problems with this is that amphetamines and their variations are categorized as Schedule II drugs because they are highly addictive. Other chemicals in this class are the ever popular cocaine, codeine, opium, and morphine. Distributing these drugs without a prescription classifies one as a drug dealer and a felon. Many acquire the drug by feigning ADHD symptoms to obtain a prescription. They can then use the pills for their own purposes or sell the unneeded to others. Not surprisingly, many of the students taking the drug in an uncontrolled environment develop a dependency, or move on to other, more dangerous drugs. The issues associated with this article and with this topic were discussed previously in Amphetamines, Good Grades, ADHD, Addiction, and Drug Abuse.

It has become widely accepted that these ADHD-issued drugs can help students perform better on tests. What is astonishing is that some physicians have extended this experience to conclude that these drugs can improve academic performance in general, and that they should be administered to children who are struggling academically even if they do not have the symptoms of ADHD. A more recent article in the New York Times—again authored by Alan Schwarz— discusses this new development: Attention Disorder or Not, Pills to Help in School.

"’I don’t have a whole lot of choice,’ said Dr. Anderson, a pediatrician for many poor families in Cherokee County, north of Atlanta. ‘We’ve decided as a society that it’s too expensive to modify the kid’s environment. So we have to modify the kid’."

"Dr. Anderson is one of the more outspoken proponents of an idea that is gaining interest among some physicians. They are prescribing stimulants to struggling students in schools starved of extra money — not to treat A.D.H.D., necessarily, but to boost their academic performance."

"It is not yet clear whether Dr. Anderson is representative of a widening trend. But some experts note that as wealthy students abuse stimulants to raise already-good grades in colleges and high schools, the medications are being used on low-income elementary school children with faltering grades and parents eager to see them succeed."

To avoid legal issues the Dr. Andersons of the world wish to claim that everyone issued the drug has the appropriate set of symptoms for ADHD. However, the article quotes parents of some patients that claim they have children taking the drugs who do not have ADHD. It is easy for a child to feign symptoms or for parents to report false symptoms if they believe it will help their child. This article and the previous referenced article by Schwarz would seem to make doctors about the most easily bamboozled species on earth. One suspects that there is more than a little complicity involved in the doctors’ actions.

Anderson certainly realizes that there are risks in the path he has chosen to take. The article describes the situation of one family of patients.

"On the Rocafort family’s kitchen shelf in Ball Ground, Ga., next to the peanut butter and chicken broth, sits a wire basket brimming with bottles of the children’s medications, prescribed by Dr. Anderson: Adderall for Alexis, 12; and Ethan, 9; Risperdal (an antipsychotic for mood stabilization) for Quintn and Perry, both 11; and Clonidine (a sleep aid to counteract the other medications) for all four, taken nightly."

"Quintn began taking Adderall for A.D.H.D. about five years ago, when his disruptive school behavior led to calls home and in-school suspensions. He immediately settled down and became a more earnest, attentive student — a little bit more like Perry, who also took Adderall for his A.D.H.D. "

"When puberty’s chemical maelstrom began at about 10, though, Quintn got into fights at school because, he said, other children were insulting his mother. The problem was, they were not; Quintn was seeing people and hearing voices that were not there, a rare but recognized side effect of Adderall. After Quintn admitted to being suicidal, Dr. Anderson prescribed a week in a local psychiatric hospital, and a switch to Risperdal."

Like other Schedule II drugs, one has to increase the dose as the body becomes accustomed to it in order to have the same effect. These drugs also have side effects, and the easiest way to counter a side effect is by adding a drug to counter the effect. Hopefully, that drug does not produce another side effect. It often requires a "cocktail" of mind-altering drugs to "stabilize" a psychiatric patient.

Dr. Anderson seems to believe the chemicals can be a substitute for a good educational environment: good teachers, healthy learning environment, supportive parents.... It is not explained how long the children are expected to take their drugs in order to achieve whatever it is they are expected to achieve.

Is there any evidence that what Anderson is doing makes sense?

L. Alan Sroufe discusses the use and misuse of ADHD drugs in another context, but his findings are relevant here. His article, Ritalin Gone Wrong, also appeared in the New York Times.

"Attention-deficit drugs increase concentration in the short term, which is why they work so well for college students cramming for exams. But when given to children over long periods of time, they neither improve school achievement nor reduce behavior problems. The drugs can also have serious side effects, including stunting growth."

"Sadly, few physicians and parents seem to be aware of what we have been learning about the lack of effectiveness of these drugs."

"Moreover, while the drugs helped children settle down in class, they actually increased activity in the playground. Stimulants generally have the same effects for all children and adults. They enhance the ability to concentrate, especially on tasks that are not inherently interesting or when one is fatigued or bored, but they don’t improve broader learning abilities."

The emphasis is mine.

"To date, no study has found any long-term benefit of attention-deficit medication on academic performance, peer relationships or behavior problems, the very things we would most want to improve. Until recently, most studies of these drugs had not been properly randomized, and some of them had other methodological flaws."

"But in 2009, findings were published from a well-controlled study that had been going on for more than a decade, and the results were very clear. The study randomly assigned almost 600 children with attention problems to four treatment conditions. Some received medication alone, some cognitive-behavior therapy alone, some medication plus therapy, and some were in a community-care control group that received no systematic treatment. At first this study suggested that medication, or medication plus therapy, produced the best results. However, after three years, these effects had faded, and by eight years there was no evidence that medication produced any academic or behavioral benefits."

It seems Dr. Anderson is risking the lives of his young patients in seeking something that is unattainable. Perhaps the cure for a bad educational environment remains the traditional one: a good educational environment.

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