Summary: With diagnosis of attention disorders on a substantial rise, medication is useful, but is not a panacea, and kids with these disorders are a flock of cultural canaries.
The rate of growth of the number of school age kids who have been diagnosed with either ADD (Attention Deficit Disorder) or ADHD (Attention Deficit Disorder with Hyperactivity) has been nothing short of astounding, and has been so atypical of normal change curves in social/medical phenomena as to sound the alarm. Epidemic?
According to Alan Schwarz and Sarah Cohen of the New York Times writing in the April 1 Seattle Times, the number of such diagnoses is 53% higher than a short decade ago, with a 16% increase since 2007. 19% of high school males have been diagnosed. What is going on here? Is it only a rise in diagnosis due to greater awareness on the part of physicians?
Well, some of that I think. But there’s more.
ADD is characterized by difficulty paying attention; the diagnosis includes such descriptors as distractible, forgetful, disorganized, and procrastination – all of which derive from inattention to time, place, and task. Such students typically struggle in school, if not in life.
ADHD adds hyperactivity and impulsivity into the same mix. This is the kid who bounces around the classroom, cannot sit still, and so conflicts with the hand of the teacher, who after all must have a semblance of order. Sometimes the diagnosis is confused with the gender, Boy.
The disorder has been traced in part to immaturity of the frontal lobe, seat of organization and order – that is, of executive function. Boys are known to take longer to mature cognitively in those ways; since it may be as late as age 25 before full frontal lobe maturity is attained, boys in particular with ADD or ADHD can have an extended troubled road to their education. Hence, nearly one in five high school boys have been diagnosed with an attention disorder.
While we have long known that the proper way to treat such students in a formal setting such as school is to provide a structured framework within which they can function more capably – that is, provide the structure that students cannot provide for themselves — such intervention requires more staff and is expensive.
In recent years the use of medications has skyrocketed along with diagnosis. Stimulants such as Adderall and Ritalin have the paradoxical effect in folks with true ADD or ADHD of slowing their tendency to shift focus, and thereby allow them to sustain attention better, to track the requirements of a course more capably, stay organized to purpose, and complete assignments on time. Voila! A student! 10% of high school boys take one or another of the appropriate medications.
Because there is substantial evidence the medications can help with school success, the heightened need for progress in school as a precursor to economic competitiveness has put great pressure on both the medical system and the educational system to provide chemical remedy for all manner of student dysfunction. While clearly school failure stems from many causes, it is true that a significant percentage of individual school dysfunction includes elements of ADD. Lacking easily accessible fixes for poverty, abuse, and divorce, the deficits of attention deficit can at least be approached by medication, and so the pressure is on. With the pressure there is danger of over diagnosis.
Moreover, Schwarz and Cohen report that the standards for diagnosis of ADD and ADHD will change with the new DSM (Diagnostic and Statistical Manual), the bible of mental health diagnosis, scheduled to come out next month. Among other changes will be the requirement that symptoms merely “impact” daily activities, whereas the language being replaced sets a higher standard – to this point the symptoms must “impair” daily activities. The upshot of these and other changes likely will be to increase the rate of diagnosis.
While we must assume there are physicians influenced by their practice with real kids who argue in good conscience for wider availability of the medication for less disabled kids, it is worth noting that the sale of medications to treat attention disorders has gone from $4 billion in 2007 to $9 billion in 2012. Follow the money. It doesn’t take the depths of paranoia to wonder how much drug company profit motive lurks in these diagnostic changes.
I am not against the use of medication to treat these real problems (though they are not on the order of what I usually think of as illness) because kids with ADD clearly have problems adapting to the behavioral requirements of the current classroom environment, and some solution is needed. In full disclosure, such medications have played a positive if ambivalent role in my own household.
However, first there is a practical problem that tempers my thinking. With high school kids, mostly boys in my experience, there is a common rhythm or two around the use of medication.
Parent, dismayed at Johnnie’s lackluster performance in school, and herself stressed out by the demands of making a buck without adequate education, consults the counselor. Counselor gathers input from teachers, which in turn tells a familiar tale. Backpack looks like a bomb went off inside, assignments are often missing or, if not missing, are incomplete. He does poorly on tests, in fact seems to have missed a significant chunk of material delivered in the classroom. He is often off task in class; in fact, there have been a few phone calls home already about Johnnie’s behavior. Etc.
Counselor (or teacher or vice principal sometimes) brings the conversation around to attention disorders. Johnnie seems classic. Often these days counselor learns the subject came up during earlier academic and behavioral struggles, in elementary or middle school. Medication may even have been tried, perhaps with mixed results, but often has been discontinued for a variety of different reasons.
Johnnie is brought into the conversation. Yes, in fact, he tried Ritalin in ninth grade. Mom then reports he resisted taking it; she was advised by the doc to structure him but leave him the responsibility. The upshot — Johnnie took the medication inconsistently or not at all.
Queried more closely, Johnnie admits, as have a large percentage of young men I have interviewed under similar circumstances, he doesn’t like how the meds make him feel. He will acknowledge that the stimulant helps him focus better in school, and his grades actually improved, but in various ways he says he “didn’t feel like himself,” lacked spontaneity and the sense of fun both he and his friends valued.
Sometimes kids have struck me as over-medicated when they make such statements, and have even seemed to have slipped into a mild dysphoria, which has led me to recommend the parent re-consult with the doc for an adjusted dosage or a different medication that would affect the student’s body and mental perspective differently.
But this downside to the medication has pervaded my efforts and those of parents to short circuit some of the liabilities of ADD and ADHD, and so have limited the otherwise promising capacity of a range of medications to improve school performance before years of school dysfunction leave the kid in an academic hole from which he may never fully recover, despite native intelligence. All this is another way of saying beware of panaceas.
By the way (parenthetically), I think there is an acceptable way to approach the yin/yang of experiences with stimulant medication. The key lies with the kid accepting responsibility for the use of medication, and defuse potential battles between kid and parent over what he puts into his body, because the parent ain’t gonna win that one, particularly with an adolescent. But, eventually some or even most kids will mature to the point that they want to do better in school, despite the down side they have experienced with the medication. At that point they are best advised to find their own balance in consultation with their doc. They should seek that sweet spot that gives them some better focus without unduly subduing their spirit. Sure, they could do better in school with a higher dose, but at a price the kid simply does not want to pay. His call, because he gonna make the call anyway.
There’s another observation about the phenomenon of attention disorders that puts them in the context of contemporary culture.
Without here citing a host of scholarly and popular writings, it is evident many writers have dissected American cultural pathways to lament the waning of structure in our society. Few would go back to the 50’s, its hide bound grey flannel suit days and its exclusions of large parts of our population from normal benefits of association.
On the other hand, the cultural revolutions of the sixties and seventies, while liberating to people in a variety of ways, has left consensus cultural value in a quandary, and our people with a relativistic sense of right and wrong. More perniciously, our young have had too many boundaries lifted from their untutored and unready psyches.
In fact, we adults have things to teach our young about how to live, how to progress, how to be a social being in the company of others and much more. But we have lost our own sense of authority in what we do know, and so our children have tended to drift on a sea of toys, cell phones, and IPads that have given them no idea how to work for something of value and be accountable.
The direction we give our kids is a necessary psychological structure through which they can explore and interpret the world, and eventually find their own unique way. But they need the developmental assistance of the template we give them; we don’t give them enough of this kind of structure.
Students with ADD and ADHD are a kind of cultural canary, because they more than their peers need structure in order to help them order their attention.
In effect, expressions of personality are contoured by the cultural context in which they are to be expressed. The same forces of the fifties that oppressed also salvaged over active and inattentive kids, and gave these students an assist in focus.
The decline of societal direction for kids suggests one possible answer to the perplexing rise in diagnosis of attention disorders. Kids forty, fifty or more years ago grew up in a structured society in which the parent down the street supported other parents and the school in a kind of cultural synchronicity. Kids whose frontal lobes were less developed had a cultural nexus that embraced them and did not permit the dimensions of variance we now allow. The same kid so contained in 1960 becomes the medicated kid in 2013. Boundaries of all types have loosened, some for the good, but in this particular case the result is to undercut the same kid’s ability to prosper. And so here we are.