Last month, my wife and I spent a weekend with a couple of old friends. In the process of catching up, we learned that they had become the godparents of the son of a couple they know well. The boy is now 10, but they’ve known him since he was a baby. In describing their new charge, they dropped the information that he had been diagnosed with ADHD several years previously. But the parents had done an unusual thing; they had refused their doctor’s advice to medicate their son.
They allowed him to be who he is and, if that meant some odd behaviors, they would deal with them. If it meant closer supervision of homework or other activities, they would do that too. My response was remarkable; I was relieved. I’m so used to the routine medication of boys that I was gratified to learn that these parents had taken the opposite path. That was some years ago and their son is doing fine. According to our friends, he still behaves in somewhat strange ways on occasion, but they characterize him as entirely normal and doing well in school. Which brings us to this article (Globe and Mail, 10/20/10). Its headline asks “Are we medicating a disorder or treating boyhood as a disease?” To which the obvious answer is “some of both.” The rest of the answer, it seems to me, is “to the extent we’re doing the latter, we should stop.” The article appeared in the Canadian press, and so the numbers refer to Canadian boys. They are daunting. Last year, some 2.9 million prescriptions for Ritalin and other drugs aimed at ADHD were issued. Over 75% of those were directed at young boys. The 2.9 million prescriptions is an increase of 55% in just four years, but that increase is in fact about the average for the past decade.
“It certainly suggests the drugs are being abused,’ says Gordon Floyd, president and CEO of Children’s Mental Health Ontario. “There’s a desire for the quick fix … the idea that – ‘oh, we’ll fix this with a pill’ – rather than spend a few months in counselling, is pretty appealing.’
While it’s true that the developing brains of boys have greater susceptibility to certain neurological conditions than do girls’, conditions like dsylexia have rigorous tools that allow accurate diagnosis. ADHD has, practically speaking, no such thing.
Diagnosing ADHD has been a medical minefield ever since the rise of the so-called Ritalin Generation in the 1980 and 90s. With no blood test or any other biological means to confirm an ADHD case, psychiatrists, psychologists or a general practitioner diagnose children after a clinical assessment or, often, with behavioural reports from parents and teachers.
But evaluations are subjective and the distinction between ADHD symptoms and standard childhood traits can be quite subtle – such as forgetfulness, and fidgeting.
“We don’t have a biological test to rule out ADHD and that gives rise to the possibility that ADHD may be misdiagnosed, or missed,’ says Rosemary Tannock, a psychologist at Toronto’s Hospital for Sick Children who studies children with the disorder.
Although brain imaging can show the type of cortical development or lack thereof indicative of ADHD, that is rarely done. Behavioral observation is usually the diagnostic method of choice and that of course leads to errors and over-diagnosis. After all, one of the hallmarks of ADHD is the inability to sit still and concentrate, behaviors that teachers like their students to exhibit. Classrooms run more smoothly without ADHD students. So it should come as no surprise that, in some Canadian schools, there’s a virtual pipeline from classroom to physician to pharmacy.
In certain boards, Dr. Roberts says, teachers are more likely to say to parents – “I’m having a problem with [your] child, and so you should go and see Dr. So-and-So,’ confident the doctor will recommend drugs, says Dr. Roberts. “Some parents have certainly told me that they have felt they could not take their child back to school unless he was taking a medication …I think we’re jumping to medication too quickly.
“There’s no question if you have a child that’s going to sit quietly in your classroom, you’re going to be a happy teacher.’
And apparently the long-term effects of ADHD medications are little known but potentially harmful.
[Q]uestions linger about their long term safety – a U.S. study last year suggested that Ritalin, or methylphenidate, could have unknown consequences on crucial brain systems. As well, Health Canada, and later, the U.S. Food and Drug Administration, warned a few years ago that the stimulant drugs may be dangerous for those with underlying heart problems – and those who do not actually have ADHD.
Important as they are, the medical issues surrounding ADHD diagnoses and medication aren’t the only ones. The question remains, “why boys?” Yes, they’re more active than girls on average, but we’ve always known that but have only been treating boyhood as a malady for the past three decades or so. The behaviors haven’t changed, but our description of them has. Time was when parents shook their heads and said somewhat ruefully, “boys will be boys,” they did it with a smile. There was always a measure of appreciation for the energy, imagination and creativity, all mixed with the measure of anarchy that was boyish behavior. No longer. Now speaking out of turn is called a disorder, wrestling with a friend is “aggressive” and “violent,” converting a balsa-wood toy airplane into a boat is considered “destructive.” Is that why the province of Quebec has Canada’s highest dropout rate among boys, an amazing 40%, while simultaneously medicating more of its boys than any other province? Do boys respond to their drugging by abandoning the system that requires it? I would suggest that there is a cultural and political dimension to all of this. For about four decades, we’ve been describing much male behavior in pejorative terms. That’s been true whether the descriptions made much sense or not. Feminist and renowned author Doris Lessing memorably described her horror at the routine “rubbishing” of men and boys she witnessed in a primary school class. Our culture teaches college students – including those who will go on to become teachers – that to be masculine is to be aggressive, violent and controlling. Are we surprised when those teachers, confronted with unruly boys in their classrooms, seek a way to make their classes run more smoothly? And if that way means medication that diminishes the behaviors that teacher has learned to think of as dangerous at worst and inappropriate at best, does she think of it as killing two birds with one stone ? Of course there are many cases in which a child truly cannot learn without behavior-modifiying drugs. But we need reliable ways of distinguishing those cases from appropriate boyish behavior. Perhaps more importantly, we need an educational culture that doesn’t view the latter as an oxymoron. Thanks to Patrick for the heads-up.