Implications for a diagnosis

Excerpt from chapter 18, “Physical Safety: The Student Body,” in Creating Emotionally Safe Schools (by Jane Bluestein, Ph.D., Deerfield Beach, FL: Health Communications, Inc., 2001). The material shared here was taken from the manuscript from this book. The actual published version may be slightly different.

Public schools have begun to issue ultimatums to parents of hard-to-handle kids, saying they will not allow students to attend conventional classes unless they are medicated. In the most extreme cases, parents unwilling to give their kids drugs are being reported by their schools to local offices of Child Protective Services, the implication being that by withholding drugs, the parents are guilty of neglect.
—Lawrence H. Diller [205]

Desks were uncomfortable, but it was not wise to move around much, and fidgeting earned you a day in the corner. Shameful!
—Elaine Lesse

There is no ‘ADD child,’ but many different kinds of children who are hyperactive and inattentive for many different reasons.
—Thomas Armstrong [206]

When faced with an ADHD labeled child, adults have two divergent choices: transform themselves and then the education system, or suppress the child.
—Carla Hannaford [207]

When I can’t stop diddlin,’ I just takes me Ritalin. . .
—Bart Simpson

I think I have Attention Surplus Disorder.
—Lauren [208]

In the time I’ve been researching the various topics for this book, perhaps no single subject has triggered the intense reactions and controversy as those related to Attention Deficit Hyperactive Disorder [209] and its treatment. During this time I met a few educators who saw the growing numbers of students on medication as an answered prayer (a few of whom fretted about the increasing resistance from parents when approached with suggestions to go this route). But the majority of respondents and interview subjects were more than a little nervous about this trend. Looking at the statistics, these concerns are understandable.

One of the problems seems to be the gap between the portion of the student population who would supposedly qualify for a true ADHD diagnosis and the portion of the poulation actually being identified and treated. The exact number of kids with ADHD is not known, although typical estimates range between three and five percent of school-age children. [210] But take a look at how many kids have been labeled as ADHD—and are on medication for this condition—and the numbers are significantly higher. In 1970, 150,000 individuals were identified as ADHD. This number grew to a million in 1990, with six million reported ten years later. This number represents twelve to thirteen percent of the schoolchildren in the U.S. In schools in high poverty areas, the percentages may run as high as 20 to 30 percent of the entire student body. [211] In certain programs for troubled kids, more than half of the students were reported to be on ADHD medication.

Further, the trend to medicate children is reaching into an increasingly younger population. According to a study of more than 200,000 preschool-age children, “the number of two- to four-year-olds on psychiatric drugs, including Ritalin and anti-depressants like Prozac, soared 50 percent between 1993 and 1995.” [212] In another study, this one of 223 children under three who exhibited developmental or behavioral problems, 57 percent were being treated with drugs, most commonly Ritalin, clonidine and dextroamphetamine; one third were medicated with more than one prescription. (Some of the children on Ritalin required an additional prescription to counteract Ritalin’s side effects. [213]) Joseph Coyle of Harvard Medical School’s psychiatry department calls the dramatic increases in prescriptions to preschool-aged children troubling, “given that there is no empirical evidence to support psychotropic drug treatment in very young children and that there are valid concerns that such treatment could have deleterious effects on the developing brain.” [214]

Diagnosing ADHD is another source of controversy. “There are no objective brain-based tests that are routinely used to detect the presence or absence of these behavior disorders,” report Karr-Morse and Wiley. Therefore, ADHD is typically diagnosed fairly subjectively, using a series of behavior checklists which are completed by the parents, teachers and, usually, a professional diagnostician. [215] The checklists typically includes a set of inattentive behaviors, such as being easily distracted by irrelevant sights and sounds, failing to pay attention to details, making careless mistake, not following directions, losing or forgetting things or avoiding tasks that require sustained mental effort. They also include a list of behaviors which reflect hyperactivity and impulsivity, such as being restless, fidgeting or squirming, leaving a seat when sitting or quiet behavior is expected, running or climbing when expected to sit quietly, seeming to be “driven by a motor,” blurting out answers or showing difficulty waiting in line or for a turn. In some cases, individuals will meet the criteria from one list or another; in others, they will be characterized by behaviors from both lists. [216]

As educational coordinator and ADHD specialist Linda Classon observes, without a “pure scientific way to diagnose ADHD, we will identify it the same way we identify a duck.” In other words, if it looks like ADHD and sounds like ADHD, we’re gonna call it ADHD. The only problem is, many of the behaviors on this list can be explained by—or overlap with—a number of diagnoses besides ADHD. Depending on who you talk to, what we might be seeing are the “look-alike” symptoms of Sensory Integration Dysfunction, [217] Post-Traumatic Stress Disorder, [218] Reactive Attachment Disorder, [219] Oppositional-Defiant Disorders and Conduct Disorders, [220] chronic middle ear infection, sinusitis, visual or hearing problems, [221] poor diet, emotional problems, [222] sensitivity to food additives, lack of clear guidelines, inadequate feedback, lack of natural light, too-warm temperatures, [223] inadequate instructional stimulation (lack of novelty, relevance, choices or opportunities to self-manage), [224] depression, [225] child abuse and neglect (particularly during the first 33 months of life), [226] or thyroid problems. [227] Additionally, Greenspan suggests that certain children might be identified as ADHD because of temperament-related patterns, such as an oversensitivity to sounds or sights, difficulty sequencing movements or processing visual or auditory input, or a tendency to be distracted by details. [228] Other mismatches of learning styles can lead to an ADHD diagnosis. Remember, high-visual, auditory-limited teachers look for eye contact and the ability to sit still as evidence of a student’s attention or interest. As Jensen observes, “Neither of these two behaviors will come from a dominantly auditory or kinesthetic learner [who is] likely to be talkative and mobile.” [229] Armstrong agrees. “Sitting quietly in a classroom is totally against the natural inclinations” of children whose strength lies in their bodily-kinesthetic intelligence. [230] Hyperactivity may also represent a child’s attempt to manually stimulate his brain to compensate for weak electrical firings at certain neurochemical sites, says Deborah Sunbeck, [231] or an effort to mobilize his vestibular system in order to take in more information from the environment. [232] Drug counselor Beverly Davies also includes amphetamine abusers among those who are frequently diagnosed as ADD or conduct disordered. (Ironically, she notes, this type of drug is among those most frequently prescribed for these kids.) Finally, the behavioral emphasis of an ADHD label may have more status for students than any type of a learning disability classification. As Fassler and Dumas assert, some children who are having a hard time learning will deliberately misbehave “because they’d rather be labeled ‘bad’ than ‘dumb.’” [233]

Armstrong argues, “Essentially. . . ADD appears to exist largely because of a unique coming together of the interests of frustrated activist parents and a highly developed psychopharmacological technology.” Certainly, the attempt to create a medical diagnosis makes it easier to justify using a pharmaceutical remedy. However, as Armstrong notes, “unlike other medical diseases, such as diabetes or pneumonia, this is a disorder that pops up in one setting, only to disappear in another.” [234] Conventional wisdom points to some neurological disturbance in the brains of ADHD-affected children, however research has not borne this out. In November of 1998, the National Institutes of Health confirmed, in a consensus development conference dealing with the diagnosis and treatment of ADHD, that “there are no data to indicate that ADHD is due to a brain malfunction.” [235] This has led large numbers of individuals to conclude that this condition is far more behavioral than organic, with the strongest opponents citing the interests of the pharmaceutical industry in the over-promotion of both ADHD and the drugs used to treat it. [236]

But economics and politics aside, there are some real dangers inherent in the use of any drugs, particularly with children. Psychiatrist Peter Breggin, a major opponent of the use of these drugs, recites a litany of concerns, beginning with their potential for addiction and abuse which, not surprisingly, many proponents deny. [237] Although one special education coordinator cited research which suggests that kids who are identified and treated early are less likely to self-medicate with street drugs, a number of individuals (including drug counselors and educators) with whom I spoke claimed that more than a few kids are indeed using “street drugs,” as well as selling and trading their prescription meds in school. The abuse of stimulant drugs is an increasing and significant problem, and many teachers feel that their drug education programs—particularly their efforts to head off their students’ impulses to “take something” to solve a problem, are being undermined by the trend which often seeks medication far too immediately, “substituting chemistry for coping.” [238] Columnist Walter Kirn shares his concerns about the emergence of an “institutional drug culture,” warning that “a profoundly mixed message is being sent to teens when certain substances are demonized for promoting the same subjective states touted on the labels of other compounds.” [239]

But there are enough other threats to a child’s physiology, according to Breggin, to qualify psychotropic drugs as a potential risk to their physical safety in and of themselves. Consider research which suggests a relationship between prescribed stimulant use in childhood and the use of nicotine and cocaine in adulthood. Or the capacity for methylphenidate (Ritalin and other brands) to produce long-lasting and sometimes permanent changes in the biochemistry of the brain, disrupt neurotransmitter systems and hormone production or endanger the cardiovascular system. (Although ADHD advocates often point to abnormalities in the brain as a cause, Breggin counters that “any brain abnormalities in these children are almost certainly caused by prior exposure to psychiatric medication.”) Other adverse effects can include depression, psychosis, irritability, insomnia, nervousness, dizziness and attacks of Tourette’s or other tic syndromes. Likewise, there is a concern that the drug can actually worsen the very symptoms it is meant to improve, including hyperactivity and inattention, with a potential for eventual impairments in thinking ability, memory and the ability to learn. [240] And although there is no direct link between the use of prescription drugs and violence, there have been some grumblings about the number of violent kids, in particular, the high-profile school shooters, who were on these drugs. [241]

Proponents of the use of medication often point to an improvement in symptoms which, in turn, they claim, can improve behavior, relationships and learning. [242] And while it’s true that many of these drugs can indeed help kids focus, opponents often ask, “Focus on what?” Hannaford concedes that drugs like Ritalin may allow kids to attend to “repetitive school work, detail and rote memorization,” but beyond these lowest levels of cognitive functioning, “there is no evidence that Ritalin improves learning or academic performance.” [243] Nor does it help avert future problems, like school failure or delinquency, claims Breggin. [244] Further, this drug locks the brain into an organized, or focused, state of consciousness, preventing kids from shifting into an open or receptive state, which is necessary for learning. [245] Emotionally, Ritalin (and other brands of methylphenidate) have an impact as well, depressing spontaneity, curiosity, exploration, socializing and playing. Several parents complain that the drugs turn kids into “zombies” or “robots,” or that it “robs them of their bubbly personality.” Additionally, observes Breggin, “the drugs increase obsessive-compulsive behaviors, including very limited, overly focused activities.” [246]

There are issues of responsibility to consider as well. Stephen Morris, a former parochial school chaplain observes, “Challenges that teachers used to handle are being handed over to psychiatrists.” [247] And Lawrence H. Diller, a behavioral pediatrics physician who prescribes Ritalin for children, is nonetheless “alarmed by the widespread and knee-jerk reliance on pharmaceuticals by educators who do not always explore fully the other options available to deal with learning and behavioral problems in the classroom.” [248] To some, medication is simply the latest weapon in our arsenal to force conformity among children. Breggin suggests that the entire purpose of the diagnostic checklist is “to redefine disruptive classroom behavior into a disease,” claiming the behaviors considered for a diagnosis of ADHD to simply represent “a list of the behaviors that most commonly cause conflict or disturbance in classrooms, especially those that require a high degree of conformity.” [249]

Advocates for medicating kids with ADHD symptoms (and those more tolerant of an approach which includes medication) note that the meds are just a part of a comprehensive, multimodal treatment approach which includes counseling for the individual and the family, parent training, esteem building, anger management and an appropriate educational program. [250] But many children get prescriptions without the benefit of these other services. Alternatives to using drugs to change children’s behavior and learning abilities require more effort on the part of adults. Debra Sugar suggests that in many instances, medicating kids give the grown-ups an excuse not to change. “Parents and teachers stop asking questions once kids are on meds,” she says. The same may hold true for some kids. Several teachers commented on kids “using” the label to their advantage. One noticed that as soon as one of her students was diagnosed, “he stopped bothering to control his mouth. ‘I’m ADD,’ he’d tell me.” Perhaps this can also explain how some children can go for long periods of time between check-ups once that initial prescription is filled. Psychologist Shannon Croft suggests having prescriptions monitored on a monthly basis. [251] But more commonly, psychiatrists write prescriptions for six to twelve months at a time, and several educators told me that some of the kids in their classes hadn’t had their prescriptions checked or changed in more than two years.

To be honest, I don’t care whether we label this cluster of behaviors as ADD, ADHD, or something else altogether. Likewise, I’m less concerned with whether these behaviors represent a “disease,” per se, or simply an annoyance. These behaviors are a reality for many kids, and their teachers and parents as well. What concerns me most, however, is how we, the adults, deal with them, and the degree to which we are willing to change our own behaviors and approaches, particularly with regard to instruction and discipline, as well as the physical and environmental factors we’re willing to consider, examine and modify as needed. It will always be easier to medicate children, but regardless of the apparent improvements this approach may seem to offer, I think we owe it to our students to consider the cost, including the very real potential for serious, long-term harm. My point is, that whether “scientifically proven” or not, there are a number of other less invasive and less potentially harmful alternatives to medication which, I believe, can offer the solutions and relief we all are seeking, alternatives that don’t require trying to fit every peg into the same square hole.

I would challenge us all to make a few small and subtle changes here and there and see what happens. Accommodate a wider variety of learning and temperament styles, modality preferences and intelligences, and increase factors like novelty and relevance in our instruction. Encourage good breathing, water consumption and frequent movement in and out of the classroom. Try minimizizing television, cleaning up the physical environment and becoming more conscious of what we feed them. Improve the quality of our “discipline” and motivation strategies and give kids more input and choices within the limits we set for them. Be respectful of kids’ needs, maintain good boundaries, build trust and mutual respect, and make a conscious effort to accept and value and reinforce them all. [Note: Many of these strategies are discussed in greater detail in previous chapters of this book.] Do any or all of these things and then see if we can’t get by on fewer prescriptions. Because any one of these changes might just reduce some of the ADHD-like behaviors we’re seeing. But our cautions about drugging children go even deeper than these results. They speak to priorities, coping skills and problem solving abilities—and, to some degree, our willingness to withstand the allure of a quick fix. For in the long run, perhaps we’ll all be well served if we can resist the urge to “take the edge off” the way kids experience life—or the way we experience kids.

205 Lawrence H. Diller, “Just Say Yes to Ritalin!” Available: Mothers Who Think Web site, [Internet, WWW], Address: http://salon.com/mwt/feature/2000/09/25/medicate/index.html.
206 Armstrong, The Myth of the ADD Child, 34.
207 Hannaford, Smart Moves, 198.
208 Character on short-lived television series, It’s Like, You Know, Aug. 31, 1999 broadcast.
209 This includes attention problems, hyperactivity and impuslsivity, which are commonly associated with ADHD
210 Jacobson and Schardt, 1; “Ritalin Overprescribed and Dangerous, Study Says,” reprinted from Health Watch newsletter, (Feb. 2000); Sandra Reif, Reaching and Teaching Children with ADD/ADHD, resource handbook to accompany training (Bellevue, Wash.: Bureau of Education and Research, 1999), 12. Note: Reif cites the existence of studies which suggest that as many as eight percent of students would qualify.
211 Fred A. Baughman, “The Rise and Fall of ADD/ADHD” (Oct. 19, 2000). Available: [Internet, WWW], Address: http://sightings.com/general4/add.htm; Peter Breggin, “On the Impact of Psychoactive Drugs on Children,” transcript of testimony presented before the Subcommittee on Oversight and Investigations , Committee on Education and the Workforce. Available: Sightings Web site, [Internet, WWW], Address: http://sightings.com/general4/addpsy.htm.
212 Lindsey Tanner, “Psychiatric Drug Use Up for Children,” Albuquerque Journal (Feb. 28, 2000).
213 ”Pampers, Pacifiers and Prozac,” Pure Facts, newsletter of the Feingold Association of the United States, (Sept. 1998): 1; Kelly Patricia O’Meara, “Doping Kids,” Vol. 15, No. 24, June 28, 1999. Available: Insight on the News Online [Internet, WWW], Address: http://www.insightmag.com/investiga/apec11.html.
214 Tanner.
215 Karr-Morse and Wiley, 110. Note: Diagnosis is similar for other “disruptive behavior disorders,” including Oppositional-Defiant Disorders and Conduct Disorders.
216 Jacobson and Schardt, 2 (adapted from Attention Deficit Hyperactivity Disorder, National Institute of Mental Health, 1994); “The Disability Named AD/HD: An Overview of Attention-Deficit/Hyperactivity Disorder,” (2000). Available: CHADD (Children and Adults with Attention-Deficit/Hyperactivity Disorder) Web site, [Internet, WWW], Address: http://www.chaddlorg/facts/add_facts01.htm; Reif, 8-9. Note: In general, the DSM’s guidelines suggest that the behaviors appear before age seven and continue for at least six months. “Above all,” note Jacobson and Schardt, “the behaviors must create a real handicap in at least two areas of a person’s life, such as school, home, work or social settings.”
217 Kranowitz, 17. Note: The main difference between ADHD and Sensory Integration Dysfunction being “a child’s unusual responses to touching and being touched, and/or moving and being moved.”
218 Perry, 2.
219 ”What is Attachment Disorder?” Available: [Internet, WWW], Address: http://members.tripod.com/~radclass/slide02.html. Note: “Experts in R.A.D. (Reactive Attachment Disorder) estimate that this disorder has been misdiagnosed as Bi-Polar Disorder or Attention Deficit Disorder in 40 to 70 percent of the cases.”
220 Karr-Morse and Wiley, 110.
221 Janet Zand, “Hyperactivity,” excerpted from Smart Medicine for a Healthier Child, (1994). Available: Health World Web site, [Internet, WWW], Address: http://healthy.net/asp/templates/article.asp?PageType=article&ID=1589.
222 ”Ritalin Overprescribed and Dangerous.”
223 Jensen, Completing the Puzzle, 47.
224 Armstrong, The Myth of the ADD Child, 13, 128.
225 Fassler and Dumas, 65, 71.
226 Karr-Morse and Wiley, 123.
227 ”Thyroid Disease: Related Conditions,” (2000). Available: About.comWeb site, [Internet, WWW], Address: http://thyroid.about.com/health/thyroid/cs/relatedconditions/index.htm. Note: ADD/ADHD was included among a number of “conditions and diseases that are related to or worsened by thyroid disease.” This condition was also included among the personal experiences of certain survey respondents and others involved in the development of this book.
228 Greenspan, The Growth of the Mind, 150.
229 Jensen, Creating the Puzzle, 47.
230 Thomas Armstrong, “Learning Differences—Not Disabilities,” in Multiple Intelligence: A Collection, Fogarty, Robin and James Bellanca, Eds. (Arlington Heights: IRI/SkyLight Training and Publishing, Inc., 1995), 226.
231 Sunbeck, 81. Note: Sylwester suggests that “lower metabolic activity and specific neurotransmitter deficiencies in brain stem and limbic system structures” might also play a role.
232 Williams and Shellenberger, 1-7; Hannaford, Smart Moves, 35, 118.
233 Fassler and Dumas, 72.
234 Armstrong, The Myth of the ADD Child, 13.
235 “Inconsistencies, Confusion in the Treatment of ADHD,” Pure Facts, newsletter of the Feingold Association of the United States, special issue ontreatments for ADD/ADHD: 1; also Baughman; Breggin.
236 Breggin; Baughman. Note: Pediatric neurologist Fred Baughman calls it “the single, biggest health care fraud in U.S. history.” Indeed, a number of major lawsuits have been brought against Novartis, the manufacturer of Ritalin for conspiracy and fraud in advancing their aims at the expense of children.
237 Breggin; “Connecting with Kids,” News 4 KOB-TV (July 28, 1999). Note: Ritalin is pharmacologically similar to cocaine and is classified as a Schedule II drug, the most addictive in medical usage. (O’Meara) Psychologist Shannon Croft, quoted in the television interview, notes that Ritalin can be “quickly addictive” when snorted.
238 Armstrong, The Myth of the ADD Child, 45. Note: Most of the teachers and counselors, including some substance abuse specialists, are far more concerned about what they see as an overprescription for stimulant drugs than they are about other drugs like anti-depressants.
239 Kirn, 48-49.
240 Breggin; O’Meara; “Ritalin Overprescribed and Dangerous.”
241 O’Meara.
242 ”Medical Management of Children and Adults with Attention-Deficit/Hyperactivity Disorder,” (2000). Available: CHADD (Children and Adults with Attention-Deficit/Hyperactivity Disorder) Web site, [Internet, WWW], Address: http://www.chaddlorg/facts/add_facts03.htm. Note: It may be worth noting that CHADD, which claims that “for most children and adults with AD/HD, medication is an integral part of treatment,” is financially supported by Novartis, the pharmaceutical company that makes Ritalin.
243 Hannaford, Smart Moves, 199-200; also Breggin.
244 Breggin; “Ritalin Overprescribed and Dangerous.”
245 ”How Food and Additives Affect the Brain,” 3; Hannaford, Smart Moves, 199.
246 Breggin; Tanner; “Ritalin Overprescribed and Dangerous.” Note: As someone who used a variety of diet pills and other stimulants—prescription and street drugs (including Ritalin)—for a number of years, I can personally attest to all-nighters that ended up being devoted to making sure all the pencils in the house were the same size instead of studying or finishing a term paper. And although I was sure that these drugs made me quite articulate, I’m equally certain that my professors would have preferred papers with sentences that didn’t run on for two pages.
247 Quoted in Walter Kirn, “The Danger of Suppressing Sadness,” Time Magazine. Vol. 153, No. 21 (May 31, 1999): 48-49.
248 Diller.
249 Breggin.
250 Chua-Eoan, 48; Fassler and Dumas, 64; Hannaford, Smart Moves, 201; “The Disability Named AD/HD: An Overview of Attention-Deficit/Hyperactivity Disorder.”
251 “Connecting with Kids.”

Excerpt from Creating Emotionally Safe Schools, by Dr. Jane Bluestein, (Deerfield Beach, FL: Health Communications, Inc., 2001). Click here for the complete bibliography with full references for the resources used in this book.

Please support this site. Click here for more information.

Related Resources:

The Animal School
Conditions with ADHD “Look-Alike” Symptoms
The “Ideal” Student: The students we were taught to teach
Literacy: What’s Movement Got to Do with It?
Some Kids (Really Do) Study Better When…
Ways to Reach More Students
Working with Different Modality Strengths and Limitations: Characteristics and strategies

Also: Why French Kids Don’t have ADHD. Article by Marilyn Wedge, Ph.D. in Psychology Today

Products:

Book: Becoming a Win-Win Teacher
Book: Creating Emotionally Safe Schools
Book: The Win-Win Classroom

Audio: Practical Strategies for Working Successfully with Difficult Students

Video: Emotional Safety and Learning Styles

Podcasts:

The Fragile Learner: Reaching and teaching struggling students, with Hanoch McCarty, with Hanoch McCarty
The Inclusive Teacher: Success with ADD and ADHD students, with Margit Crane
Movement and Learning: A partnering relationship, with Aili Pogust

Presentations:

Creating Emotionally Safe Schools: Is Your School an Emotionally Safe Place?
Dealing with Difficult Students: Practical Strategies for Success with Defiant, Defeated, and other At-Risk Kids
The ‘I-Can’ Classroom: Building for Success and Achievement for ALL Students 
“My Brain Doesn’t Work Like That”: Creating Success with Non-Traditional Learners by Accommodating Learning Differences
The Win-Win Classroom: A Fresh and Positive Look at Classroom Management

Leave a Reply

Your email address will not be published. Required fields are marked *