Asks Randy Harris:
Are children overmedicated (Particularly with regards to ADHD)?
Good question, Randy. I’m not sure, but I think the answer is probably “yes.”
Before I dive into my thoughts, I should stipulate that I am not a specialist in behavioral or developmental pediatrics, nor am I child and adolescent psychiatrist. Furthermore, since one of my partners is a developmental specialist, he does almost all of the ADHD diagnosis and treatment for our office. It’s been a couple of years since I had primary management responsibilities for ADHD patients (which suits me fine), and even then I’d only done it for a handful of years. So my opinions are perhaps as not as well-informed as those of medical providers who treat the disorder regularly, though I have many patients who are being treated for it. Also, anything I have to say on the matter is based simply on my observations, not any kind of actual research I’ve done. (I also feel I owe it to my partner to say I think he does a very good job of resisting parental and school pressure to over-diagnose, and is appropriately judicious.)
With that said, I do think ADHD is over-diagnosed and over-treated. ADHD is the most commonly-diagnosed mental health disorder of childhood, and the most recent statistics I can find show that over 10% of boys between the ages of 3-17 have been diagnosed with it at some point. That number seems awfully high to me, and there is at least some evidence that factors other than the child’s actual condition may contribute to the diagnosis, including school performance pressures and socioeconomic stress. These data are far from clear, however, so it’s unwise to jump to too many conclusions.
However, if I were to ignore my own admonition and draw conclusions about the patients most likely to receive a diagnosis of ADHD that may be suspect, I would lump them into two groups.
The first group comprise children (usually boys) who behave in a disruptive manner at school, though not always just in that context. Typically they are from families with fewer advantages, and may also attend schools where teachers have many similar students and limited resources to deal with them. There may be some kind of instability in the home environment, and parents may have fewer supports than those in more affluent communities. Often they work and do not have the opportunity to pursue non-medical interventions should they experience pressure from the school to address the disruptive or hyperactive behaviors. Parents often report a perception of mounting insistence from teachers (who often seem similarly pressured themselves) to find a solution, and medication is quite often cited as the recommended solution from the school.
Unfortunately, possible options for non-pharmacological management are often limited. Parents may simply lack the time, energy and education to successfully implement a behavioral regimen to correct the problem. It’s all very well to recommend a non-medical approach, but if that requires a more significant time commitment than a parent who is already struggling to make ends meet can afford, then the recommendation is useless. Could non-medical interventions succeed? Possibly in many cases. But life circumstances frequently moot the question.
The other group who get questionably-appropriate ADD diagnoses are another ball of wax. They tend to be adolescents, often in high school or preparing to go to college. They are much less likely to have behavioral symptoms, and are more likely to report problems paying attention in class. Surprisingly often, they report good academic performance, but cite difficulty with “focusing,” a vague term I have come increasingly to despise. It’s not that they’re not doing well, but they perceive they’re not doing well enough. The perception seems to be that any difficulty concentrating is evidence of a disorder, and that the ability to pay attention regardless of interest in the subject matter should be innate.
As perhaps you can infer from what I’ve written, I have much less sympathy for the latter group. It is one thing to be a single mother working two jobs who can’t afford to send your kids to a quality early development program. It is another thing entirely to desire (and sometime demand [futilely, in my case]) a pharmacological corrective for any kind of deficit in scholastic skill. When I do refer these latter patients for further evaluation, I generally do so with an honest statement that I doubt a mental health disorder and would question the legitimacy of a prescription, and I suggest that strategies to improve study skills might be more appropriate. I am not optimistic that these statements of mine accomplish anything, but at least I feel better about myself for having made them.
None of this is to say either that ADHD is not a real mental health disorder, or that medication cannot be appropriate and truly helpful. It is, and it can be. But I do suspect that the diagnosis is applied and medication prescribed too liberally.
I find it interesting that the tag-on advertisement to this post (which you have no control over) is for “Safe, Natural ADD/ADHD Symptom Relief.”
“(which you have no control over)”
I meant, you had no control over which advertisement is tagged on to your post. At least I assume you don’t, other than that you mention certain key words that are picked up by advertisers. (For all I know, this advertisement only shows up on my sign in and not on others.)
I’m seeing a weight-loss ad. Rather presumptious (and, sadly, accurate) of the site.
I have one for finding sexy singles. Yesssssssss…
Diamond Ranch Academy.
Ovecome Defiance, Anger, Substance Abuse, ADD/ADHD, Peer Pressure.
“Healing Families, One Youth At A Time…”
I think I should have preferred to make a joke about how *I* saw an ad for hair loss prevention.
Ummm… if we all lose focus because of small banner ads, doesn’t that indicate that ADHD is underreported?
I’m not seeing an ad for ADHD prevention. Or maybe I didn’t read the fine print. No, not ADHD. Though the browser scrolled down for me to type this reply, so maybe it changed. No, it’s the same, so scrolling doesn’t make the ad change. Or didn’t that time, anyway. No, not that time, either. And once more… Still didn’t. Let me try refreshing the screen. First I’ll copy this text so I don’t lose it, and now… No, still the same ad. Once more. No, now it’s a different ad, but still not ADHD. And if I refresh once more … Yeah, now it’s a new ad, but still not ADHD, This one’s about something called OCD. Hold on, I need to look that up…
The shifting expectations of schools, particularly for young children is a huge issue. As education has become dominated by women, the demands and expectations on children have been feminized. Coupled with increased academic focus at earlier ages, and we’re suddenly demanding young children sit for extended periods of time and engage in tasks that most simply can’t succeed in. Boys overwhelmingy struggle and rather than explore of we are failing to meet their needs, we blame them, blame the families, and offer drugs.
ADHD is very real for some people and medicinal intervention can do wonders. But that doesn’t mean every squirmy 4-year-old who doesn’t want to sit perfectly still during a 20 minute math lecture has it.
+1
As education has become dominated by women, the demands and expectations on children have been feminized.
I must admit, I would have expected more of a response to this particular line.
I wasn’t reading carefully and missed it. Lack of focus, I guess. Russell, what should I take for that?
It’s a weird statement though, considering that when I went to grade school, almost all the teachers were women, because it was one of the few jobs that women were expected to do.
Teaching was always primarily a female field, but women are now more often and better positioned to be leaders and decision-makers. This isn’t a bad thing, mind you. But a lack of awareness of how the gender (or race or class or whatever) makeup of a group can impact some of the things that group says and does, you can have problems.
It is the same reason many female students continue to struggle in math and science… Those areas are more male dominated and teaching approaches tend to shortchange girls.
When I was growing up, teachers were women but principals were men. From an equality standpoint, that was unacceptable and it’s good that’s changed. There might have been some bad with the good, though.
math and science approaches shortchange people who aren’t able to sit still and do formulae. In short: a ton of people who would be GOOD at actual math and science are systematically weeded out, in college or before.
It’s something I noticed when I started doing math at university (both in economics courses as well as 1 or 2 pure math courses). High school math pedagogy is totally different to university math pedagogy to the point where they’re practically different subjects.
One of my regrets is not pursuing any math courses at university. I did calculus in high school and did decently (B’s and A’s in a three semester program), but thought I couldn’t do anything beyond that. I wish I had at least given it a try to see what it was like.
What’s the historical basis for this “feminized environment” claim? People always bring it up to explain why today’s boys have more trouble sitting down, shutting up, and doing their work than their female peers. But it seems to me that those expectations predate any particular “feminization” of teaching, whatever that might mean.
They say the battles of the British Empire were won on the fields of Eaton. Boys in the most “masculine” environments were still expected to sit in their seats and do their work, and somehow they pulled it off just fine.
When my grandmother taught school 60 years ago, many of the teachers were female, but the standards were set entirely by men (the superintendent, the school board, etc.). Again, boys had no particular problem living up to the rigid, top-down, pedagogy that supposedly puts boys at a fatal disadvantage. It was designed by men for boys, with women and girls added to the system as an afterthought.
Schools today may be more permissive, but I’m not sure they’re more feminine. If you want to talk about why boys aren’t thriving in school, let’s talk about male privilege. The research shows that we’re more likely to explain misbehavior and poor performance by boys in terms of natural exuberance, and less likely to give girls the same benefit of the doubt if they act out. Girls who don’t meet expectations are more likely to be judged as inherently lacking in ability, rather than gifted with excess energy.
Mr. Rogers, if you listen to Limbaugh.
Poor pastor got death threats in his latter years.
Boys weren’t expected to sit and do drill-and-kill work at 4-years-old even 20 years ago, as most 4-year-olds weren’t in school. This trend combines with other tends, including the feminization (which bans things like healthy roughhousng), leaving all students, boys inparticular, in a lurch.
I doubt that most people understand this whole “feminized” thing — and I doubt it was true. I’ve read my Laura Ingalls Wilder, and she seemed to do in the one room schoolhouse the same as we were taught, more or less. maybe we got more videos.
The difference is that, back then, the people who were in school past “write your name and count to ten” were in the equivalent of a Master’s Degree program.
The other group who get questionably-appropriate ADD diagnoses are another ball of wax. They tend to be adolescents, often in high school or preparing to go to college. They are much less likely to have behavioral symptoms, and are more likely to report problems paying attention in class. Surprisingly often, they report good academic performance, but cite difficulty with “focusing,” a vague term I have come increasingly to despise. It’s not that they’re not doing well, but they perceive they’re not doing well enough.
I have this sinking feeling you’re describing bright kids who think (accurately) that school is boring.
That is essentially what I’m describing, yes. Since life is full of boring things we are nonetheless required to attend to, medicating the boredom away is not a feasible or salubrious solution.
Well, it’s not salubrious.
It’s “feasible”, for most definitions of “feasible”, though. Pot smokers have been using that strategy since forever.
Ah. I spoke inexactly. Let me rephrase — medicalizing and pathologizing a normal, human response to uninteresting stimuli is both an inappropriate use of healthcare resources, leading to unnecessary costs over time, and also distorts a proper understanding of human psychology.
Is the problem the medicating, or is the problem the medicalizing?
Because, I suspect, most of those kids know, or at least could be made to understand, that their “condition” isn’t really a pathology. But, nevertheless, they want drugs that they think can make them perform better. They grew up watching mommy and daddy enjoy their daily coffee and at that age when they’re discovering the benefits of caffeine themselves. They want another caffeine.
There’s also the “Yes, you understood the material well enough to get an A, but if you really focused you’d get an A+ and the scholarship to Yale without which your life will be shit” factor. In other words, this is a boring thing that, absent unreasonable expectations, the kid attended to just fine.
1+
He’s describing me! Well, minus the appeal for drugs.
Some of it was exactly boredom. Some of it was… a serious difficulty of focus. Poor reading comprehension, doing math problems 2 or 3 times to make sure I’m getting a consistent answer (I didn’t mix up digits, kept my plus/minus signs straight, and so on). The ability to get a complex mathematical formula exactly right, combined with an inability to carry the one. Somewhere in there the implicit assumption that I was probably not college material, outweighed by my ability to piece enough things together to compensate.
Some kids with the problems you describe legitimately have either ADD or a learning disability. But I suspect that make up a relatively small number of the patients I’m describing.
Well, to be fair, with me at least there were some real performance deficiencies that a parent or doctor could point to. At least early on, until I learned better how to compensate.
The description just jumped out at me.
1. I heard a talk given by Glen Elliott, the author of Medicating Young Minds: How to Know If Psychiatric Drugs Will Help or Hurt Your Child, and medical director of the Children’s Health Council in Palo Alto. He asked two questions: Is ADHD over-diagnosed? and Is medication over-prescribed? His answer to both is yes and no, depending upon the child and to a certain extent, the child’s geographic location.
2. I also think that school demands have become developmentally inappropriate. We are asking 5, 6, and 7 year olds to master skills that are beyond their physical and cognitive development. This idea is substantiated by three studies showing that the younger children in a given grade are more likely to have an ADHD diagnosis. The most recent study isInfluence of relative age on diagnosis and treatment of attention-deficit/hyperactivity disorder in children..
Not much to add, other than very informative post and comments. Thanks Dr. Saunders.