(submitted for a doctoral class research assignment, Fall 2009)
The explosion in modern medical innovation that followed Fleming’s discovery of penicillin in 1928 spawned the birth of a new industry – health care (Nobel Lectures, 1964). I have worked in health care my entire adult life, and the curiosity and suspicion driving my current research was seeded years ago. As a health data analyst, I performed feasibility studies for hospitals interested in expanding their business. One particular project stands out in my mind as a tipping point for my trust in the system. The project involved a new women’s center, and as I gathered data to create the profit/loss budget scenario, demographic profile and anticipated breakeven point, I began to get curious about the link between revenue projections and the push to drive patients to annual screening exams. Like most women, I was aware of the push for women forty and older to get annual mammograms, but as I prepared the population profiles, applied the insurance case mix and expected reimbursement for each procedure, then compared the revenue over time to the anticipated outlay of expense, a nagging feeling crept over me. When you purchase a single piece of equipment for $1million+ based on the assumption that patients will follow the common screening recommendations, what happens if dissenting opinions challenge that practice? Conversely, what is the driving force behind that recommendation – women’s health or financial interests of medical device manufacturers and hospitals? Interestingly, in recent weeks – more than ten years after my initial curiosity – those recommendations were challenged and the uproar that followed, though not from the financial corners, surely had some business planners wondering how the potential decrease in patients seeking screenings for breast cancer would impact their ability to recoup the investment in what by now would be multi-million dollar machines. Though not obvious parallels, it is this same curious and jaundiced eye that I turned toward the practice of managing children’s behavior with medication, wondering about the interplay between stated and unstated motives in advocating for the practice, and wondering how educators – intentionally or unknowingly – play into this paradigm.
While no shortage of villains exist in the debate on medicating America’s youth, one thing is clear: kids today are more medicated than before (Olfson, et al, 2002). As to who is driving this increase in the medical management of childhood behaviors, there are varying perspectives. Schools often cite impatient or unengaged parents, while parents will point to meddling schools, too much testing and crowded classrooms as the issues. In interviews with elementary educators, these positions quickly came to light. One educator who has children, and grandchildren – sees parents as too quick to presume an external cause for issues she believes are perhaps, non-issues.
“I think it’s easier for people to say ‘it must be this’; it doesn’t have anything to do with the way I am raising my children, or the expectations the schools have of my child. This is what the problem – I can remember – even way back then, parents coming to see (a colleague) in [another affluent suburb] with 2 year olds who were eventually going to go to his school and telling him, ‘I already know they have ADHD’… and I remember thinking ‘my word – don’t you know what terrible 2’s are?’ You know and they were identifying their kids back then – parents saying ‘I see it’ and believing they could identify it – it was really out there in the news back then – it still is now. I think we over diagnose kids”
One father of an eleven year old girl who is on stimulant medication to control her behavior provided a somewhat different perspective:
“We didn’t know what to do with her – she was increasingly out of control at home, and we were like, ‘if this is how she acts at home, what’s going on at school?’ She had a couple of issues [unintelligible] on her last few grade cards – nothing major, but – and no calls from the school or anything, you know – and, we, we didn’t want them to tell us what to do with our child; [my wife] would have gone crazy – we were just seeing this [behavior] so we took her to the pediatrician and got her on medication. We really didn’t know how else to handle her.”
Some parents seemed to be greatly influenced by their perception of what the school wanted, as this father stated. What is not known from this interview is how much the decision to medicate was motivated by fear of the school’s potential reaction and how much was impatience with a child’s disruptive behavior at home. What is also interesting in this case is that when observing his daughter (along with her brother, and several other children around the same age), she was animated, talkative, and energetic, but her behaviors in the context I observed were not outside the norm of what kids do when they are playing, especially in a group without structure. It was also interesting to note that while this girl was very obviously active and quite verbally noisy and expressive, other kids’ behaviors, though not as physically active or noisy, could easily be construed as troubled – maybe more so than hers. The main difference being that her behavior was “in your face” – the others more subversive; under the radar and less easily detected. The setting I observed was a regularly-scheduled get-together of elementary – age kids, was based on their families’ shared social connection. I did not know the medication status of any of the children in attendance other than the one eleven-year old girl. While there, I observed behaviors that included one female child (about age eight) stealing pencils or pens from other kids when they were not looking; an older child (female, about age ten) making a younger child (not a sibling; about age 7) scream by pretending to whisper in another child’s ear while staring at the younger (screaming) child; and a male child about age nine – sitting quietly, but digging his pen into the wood of the chair seat.
While admittedly brief and limited in its scope, this observation gave rise to several questions about children’s behaviors in schools: in the three scenarios I described, I was not sure that any of them were much different – or less annoying – than the very active and verbal child who is currently being medicated. Old suspicions, like the ones that emerged years ago when I assured a hospital that there were enough women terrified of breast cancer to pay for their multi-million-dollar machine in a reasonable period of time, began to take over into my thoughts. Who decided which behaviors were pathological and in need of correcting, and why? Based on interviews I conducted with several education professionals, schools seem reticent to accept any responsibility for creating the demand for medication.
“The school’s role is never to, umm, to recommend or endorse medication, so we – we diagnosis and then say ‘here’s how we can deal with it educationally, if you want to deal with it medically, it’s between you and your pediatrician’ …”
When pressed about the school’s role in recommending a child for medication, educators are quick to point out that the school is not the “bad guy”.
“We would not – the only way it would even come up is if the parents say ‘what can we do?’ Then we usually lay out options, and we would say ‘well; there are – here’s what we are going to do educationally – we can work thru behavioral therapy; we can work with some, umm, errrr – systems to try to shape behavior but umm – so that’s one option. Another option – our school psychologist is very good at laying out, umm, you know what our academic options are, what some parents have tried, some behavior therapies at home, others have tried some holistic therapies at home – fish oils, umm –umm … meditation, yes – or you can talk to your pediatrician if you think that meds might be an option’, but it’s always kind of couched in that ‘if that’s what you’re interested in, then, umm, then you can talk to your pediatrician’. It’s not ‘what you need to do is go see your pediatrician and get this child medicated’. “
Another educator, whose stance on medication as an option was much more negative, sees parents, not pediatricians, as the medication drivers.
“Parents have to work with us as a school system; what’s interfering with his learning and what’s not and that, to me is the key. We work carefully, we will solve the problem – sometimes with meds sometimes without; and sometimes you have to wait it out; sometimes you have to get through the adjustments in the beginning of the school year. Umm, I just feel that – it, it takes more than one person to decide what’s best for this child…including the doctor. I mean, I can give him the data but I still see the child every day- I can see what makes the difference. I have parents – highly-educated professionals – who overmedicate their children and I tell them that – (laughs) point blank. The kids are not even available to learn because they’re so sedated in class, and they will say to me, ‘well they’re very wild at home’, and I thought to myself, well they’re kids, they’re KIDS! And umm, I watched one kid come to school in a stupor,… I guess I’m,… I always push back at trends, and go with what I see as common sense…and [medicating children] isn’t common sense”
If schools are not recommending medication as the best option, as my (admittedly limited) research seems to indicate, why are so many of America’s youth being prescribed stimulant medications for behavior? The statistics show a clear increase in the number of prescriptions written for stimulant medication to treat ADHD between 1990 and 1999, an estimated increase of 3-to-6-fold for the period (LeFever, Dawson and Morrow, 1999). Who or what is responsible for the fact that American schoolchildren account for 80% – 90% of the consumption of all the methylphenidate (e.g. Ritalin) produced worldwide (Stolzer, 2007)? Since prescriptions are required for the acquisition of medications of this type, the medical community is an obvious factor in the pace at which behavioral issues are being managed medically, and one principal was quick to intimate that while the schools offer many options, once medical doctors are involved, it’s all meds, all the time.
“it seems umm, (pause) it feels as though when parents decide to go to their pediatrician its – it’s almost like a done-deal. We’ve filled out our rating scales, we send them in, and (pause) I have – I have seen our School Psychologist administer assessments to children and come back and say this child does not have ADHD. I don’t think I have had a parent go to a pediatrician – (nervous laugh) and I don’t want to blame the other profession, or whatever – I don’t think I’ve had a parent go to the pediatrician and say this – we need to look into this a little further,…and then come back and say ‘nope – it’s not ADHD’”
This suggests that once a parent decides to go to the pediatrician, there will be medication prescribed, and the educators couch it almost as if to say “the schools are willing to manage ADHD from a number of angles, but the physicians will always medicate”. These comments provide interesting perspective but the statements, both direct and implied, are impossible to verify or contradict without some corroborating statements from several pediatricians. These sentiments are echoed by a number of educators. Many of them voiced a perspective on the physician involvement is that not only will they (physicians) medicate almost immediately upon evaluating a child with a potential attention issue, but they (the physicians) then drop the ball in terms of follow up to determine if it is indeed the best option for the child.
“[physicians] don’t follow up with what you see after you write the prescription, like why are they crying at the drop of a hat when they never did before, umm but parents say ‘but they’re paying attention…’ and I always wonder ‘at what cost?’”
It would be especially helpful to glean, from the pediatricians’ perspective, what input they have received from the school reports, as well any information that the parents have shared on the perceived direction (or mandate) from the schools as reported to the physician when questions about medically managing the child’s issues are presented.
Another important angle missed in my research due to its limited breadth was the role that income level and socioeconomic status play on the choice to medicate. While all educators interviewed for this study indicated without hesitation that in their experience, higher incomes and socioeconomic status almost always parlay into more willingness to medicate for behavior,
“Ummm, (pauses) I – my gut tells me that the higher your SES the more willing you are to look for medical interventions; that’s what my gut would tell me. And my experience (pauses) would probably back that up. (laughs) Umm, I’m just – trying to look at numbers of kids – not necessarily who would benefit from, but parents who are willing to [medicate].”
recent research, including some out of Rutgers and Columbia suggests that it is the nation’s poorer youth who are being over-medicated, and at rates four-times that of their middle-class peers (Wilson, 2009).
My study created more questions for me than it answered. I found no solid answers to my initial inquiry: the role of the elementary educator in the prescribing of stimulant medication for children. I did, however, find several distinct avenues to pursue to uncover the paths to medication that are taken. To reach any viable conclusions, this study would need to be expanded to include interviews with pediatricians, parents from multiple socioeconomic status groups, educators from schools located in diverse neighborhoods and settings, at a minimum. Further review of research that initiated medication as an option for managing behavior issues as well as the body of work addressing the controversies about that same research will also be required. What this study did reveal however is that the answers to how children come to be medicated for their behavior are as many and varied as the children themselves, and the truth – if there is a single truth – will be as multi-faceted and complex as the children themselves.
Arnold, L.E., Abikoff, H.B., Cantwell, D.P., Conners, C.K., Elliot, G.R., Greenhill, L.L., . . .Wells, K.C., (1997). NIMH collaborative multimodal treatment study of children with ADHD (MTA): Design, methodology, and protocol evolution. Journal of Attention Disorders, 2 ( 3), 141-158.
Bekle, B. (2004). Knowledge and Attitudes about attention-deficit hyperactivity disorder (ADHD): a comparison between practicing teachers and undergraduate education students. Journal of Attention Disorders, 7(3), 151-161.
Brook, U, Watemberg, N, & Geva, D. (2000). Attitude and knowledge of attention deficit hyperactivity disorder and learning disability among high school teachers. Patient Education and Counseling, 40, 247-252.
ISOC – Internet Society (2009). “A Brief History of the Internet and Related Networks”. Retrieved from http://www.isoc.org/internet/history/cerf.shtml .
Law Library – American Law and Legal Information, (2009). “Blue Laws”. Retrieved from http://law.jrank.org/pages/4795/Blue-Laws.html .
LeFever, G.B., Dawson, K.V., and Morrow, A.L. (1999). The Extent of Drug Therapy for Attention-Deficit Disorder Among Children in Public Schools. American Journal of Public Health, 89 (9), 1359 -1364.
Mays, R., Bagwell, C. and Erkulwater, J. (2009). Medicating Children: ADHD and Pediatric Mental Health. Cambridge, MA: Harvard University Press.
Navarro, V. and Danforth, S. (2004). A Case Study of ADHD Diagnosis in Middle School: Perspectives and Discourses. Ethical Human Psychology and Psychiatry, 6 (2), 111-123.
Nobel Lectures, (1964). Physiology or Medicine 1942-1962. Amsterdam : Elsevier Publishing Company. Retrieved from http://nobelprize.org/nobel_prizes/medicine/laureates/1945/fleming-bio.html
Olfson, M, Marcus, S.C., Weissman, M.M., & Jensen, P.S. (2002). National trends in the use of psychotropic medications by children. Journal of the American Academy of Child and Adolescent Psychiatry, 41(5), 514-521.
Parry, M. (2009, October 30). Online education, growing fast, eyes the truly ‘big time’. The Chronicle of Higher Education – The Wired Campus, Retrieved from http://chronicle.com/blogPost/Online-Education-Growing/8663/?sid=wc&utm_source=wc&utm_medium=en .
Gregory, S. (2009, February 4). Are Direct-to-consumer drug ads doomed? Time, Retrieved from http://www.time.com/time/business/article/0,8599,1876679,00.html .
Rafalovich, A. (2005). Relational Troubles and Semiofficial Suspicion: Educators and the Medicalization of “Unruly” Children. Symbolic Interaction, 28(1), 25-46.
Rowland, A.S., Lesesne, C.A., & Abramowitz, A.J. (2002). The Epidemiology of attention-deficit hyperactivity disorder (adhd): a public health view. Mental Retardation and Developmental Disabilities Research Reviews, 8, 162-170.
Stolzer, J.M. (2007). The ADHD Epidemic in America. Ethical Human Psychology and Psychiatry, 9 (2), 109– 116.
Vedantam, S., (2009, March 27). Debate Over Drugs For ADHD Reignites: Long-Term Benefit For Children at Issue. The Washington Post, Retrieved from http://www.washingtonpost.com/wp-dyn/content/article/2009/03/26/AR2009032604018.html .
Wilson, D. (2009, December 11). Poor Children Likelier to Get Antipsychotics. The New York Times. Retrieved from http://www.nytimes.com/2009/12/12/health/12medicaid.html?ref=health.
Wolraich, M. L. (2007). Treatment of attention deficit hyperactivity disorder in children and adolescents:safety considerations. Drug safety : an international journal of medical toxicology and drug experience, 30 (1), 17-26.