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Overdose?


Medication can work wonders, but critics believe too many children are taking too much.


By Alain Jehlen

It was math time in the Oklahoma City third-grade class and Bobby (not his real name) was supposed to be constructing the number 38 using base-10 blocks to make a physical model of addition. But he was just sitting there. Then he started making a building with the blocks instead of a number. Katherine Bishop, his teacher, constantly had to go back to remind him what the task was. "Finally, he yelled, 'Get out of my face!' and knocked the blocks off the table. I had to take him out of the room," she recalls.

New scene, a month later: same teacher, same kid, same blocks, similar assignment. Bishop still had to remind him of the task, but then he set to work and did it. "I said, 'Well done!' He was beaming. And he got to stay with his friends and have discussions and not get into arguments."

The difference? Bobby had started taking Adderall, a common drug used for attention deficit/hyperactivity disorder (ADHD).

Statistics on drugs used to change classroom behavior are hard to come by, but informal reports say the number is growing, and in recent years, large numbers of children have been prescribed powerful anti-psychotic drugs with sometimes severe side effects.

The most common reason for medicating children is ADHD. A Centers for Disease Control study found that, in 2003, among children ages 4 to 17, 6.2 percent of boys and 2.4 percent of girls were medicated for ADHD, not counting those medicated for other behavior problems. That's about 2.5 million children. The peak ages were 9 to 12, when 8.8 percent of boys and 3.6 percent of girls were medicated for ADHD. 

Just as wheelchair ramps and handicap-accessible bathrooms help students with physical challenges attend regular classes, Adderall and the many other drugs that change behavior have played a big part in moving children who can't control their impulses into regular education.

But there's not always a happy ending.

Dos and Don'ts for Out-of-control Students

Johnny bounces around, hits classmates, throws chairs.

You're his teacher. You've already tried everything in your bag of tricks. What to do?

Here's advice from psychologist George DuPaul:

First, document the problems. Take notes. What are you observing? What seems to trigger the behavior? Do that for a couple of weeks.

Seek out people in the school who may be able to help—a counselor or school psychologist.

Finally, talk with the family, preferably face-to-face: "I have concerns about your child. Here's what I see." Do it in a nonjudgmental way, not accusatory. The first reaction of the parents is likely to be, "The teacher is saying I'm not doing my job." So keep it factual: "The behavior is disruptive to your child's learning and to my classroom. Do you see it at home? How do you deal with it?" Come up with a plan together.

If that isn't successful, or if the behavior is beyond the point where informal intervention can work, suggest that the parent talk with a physician or have an evaluation at school. 

Whether or not the child gets medicated, you will need a strategy. Physicians consider medication successful if the behavioral symptoms are reduced, but that doesn't mean the child is reading better, making friends better, or doing math better.

Here are some things NOT to say:

  • To the parent—"Your child has ADHD and you need to get him medicated." Or, "Your child is not prepared to learn. Something must be happening at home." Even if you're right, the parent won't react well.
  • To the child—(especially in front of his or her classmates): "Why can't you control yourself? What's wrong with you?"
  • To the guidance counselor—"You have to get this kid out of my classroom." At least, not until you and your colleagues try other approaches.

Take Mark, a fifth-grader with a ferocious temper. "One time, he threw a chair at me," Bishop recalls. His doctor and his parents decided to try Risperdal, a potent anti-psychotic. But he just got worse, starting angry fights on the playground that could have led to serious injuries. Several medications later, Mark's parents, Bishop, and the rest of the team working with him reluctantly agreed he should go to an alternative, more structured school.

Then there was Tommy, who suddenly had trouble breathing, his lips turning blue. He was rushed to the hospital where he was treated for a dangerous drug reaction.

Unlike physical aids, drugs that change student behavior have always been controversial. Critics say that drugs are often a substitute for skilled classroom management in school and conscientious parenting at home, and can deprive children of their full range of emotional and intellectual powers—that they leave students "drugged up."

In an informal survey of delegates to last summer's NEA Representative Assembly, some said drugs are over-prescribed. "We have medicated children instead of giving them the skills to correct themselves or improve," said a substitute teacher from Texas. But others disagreed. "I had three students who, without medication, made it impossible for the class to learn anything," said an elementary teacher from Illinois.

Leading school psychologists share much of that ambivalence. "When I see the numbers, I think there shouldn't be that many kids getting medication," says Ron Benner, a school psychologist in Bridgeport, Connecticut. "But when I look at individual children, I think, if it's helping that child, keep it up!"

Benner and Bishop are both members of the NEA special education cadre, a team of practitioners involved in national policy and professional development. Benner is also a leader in the National Association of School Psychologists.

In the last two years, newspaper articles and a television documentary have chronicled the fast-rising use of powerful anti-

psychotic drugs prescribed to children for bipolar disorder, which until recently was not thought to afflict children. According to a PBS Frontline documentary, a million children have received this diagnosis. The New York Times reported more than half a million children are being prescribed drugs that are used to treat bipolar adults, and proponents say the drugs can rescue kids and families in crisis. NEA Today's survey of Representative Assembly delegates confirmed that many teachers see a rise in the number of children diagnosed with bipolar disease.

'Something is wrong with my little guy.'

"Absolutely, there are a lot more," says school nurse Nancy Wells, supervisor of School Health in Manchester, New Hampshire, and another NEA special education cadre member. "It shows courage on the part of psychiatrists who see the symptoms and are calling it what it is. It's a more heavy-duty diagnosis than ADHD, but many parents are relieved to have the diagnosis. They say, 'This is what it is—it's not my parenting, or society, or the teacher's teaching. Something is wrong with my little guy and we can go from there.'"

The rapid rise in bipolar diagnoses, however, has set off alarms inside and outside the psychiatric profession. Critics warn that these drugs can have dangerous side effects and have not been tested for safety in the developing brains of small children. News reports reveal that drug manufacturers fund researchers who promote the use of anti-psychotic drugs in children and pay doctors to give seminars for other doctors on using these drugs.

Even if there are real cases of bipolar disorder in children, some educators wonder whether the label is overused.

What's in a label?

"Bipolar is the diagnosis of the day," says Katherine Bishop. "Also autism. Sixteen years ago when I started, it was ADHD. These diagnoses are based on a behavior rating scale that parents and teachers usually fill out. It's not a blood test. It's subjective. And many of these characteristics fall into several disorders.

"I had a student who went to the doctor for one session and, based on a behavioral checklist, was diagnosed autistic. Is he non-communicative with peers? Well, sure, sometimes. But he also bounces around. So is he hyperactive?

"Sometimes parents don't like a diagnosis and shop around for a different doctor."

Bishop says the diagnosis doesn't really affect her work. "I watch behavior. That's what my services are based on." She has strategies for dealing with children who won't follow directions, or can't sit still, or lose their tempers—regardless of the label.

But the label does have a big impact on a child's life, not least because it affects what drugs he or she will receive.

Despite the growing number of bipolar and autism diagnoses, ADHD remains the most common syndrome for which children are medicated. That diagnosis is also controversial, although ADHD has a long track record and milder drugs are used to control it.

"There's deep-seated suspicion in the Black community about the diagnosis and treatment of any of these disorders, and especially medication," says George DuPaul, a school psychologist and ADHD researcher at Lehigh University in Pennsylvania, who works with the National Association of School Psychologists. Because of that, and because many Black and low-income families lack health insurance, says DuPaul, the percentage of middle class White children medicated for ADHD is higher.

Parent suspicions were also behind a Connecticut law that bars teachers from recommending to parents that their child should have medication.

NEA Today's survey of RA delegates confirmed that teachers rarely play much role in the medical decisions. But Benner thinks they should—not in deciding the label or the drugs, but in describing the symptoms. "Teachers make good observers because they have another 25 noses to compare that nose to, whereas a parent may have only one or two," he says.   


 

More Resources

Centers for Disease Control 2003 Survey , including national and state-by-state statistics

New York Times articles:

PBS Frontline documentary, The Medicated Child

National Association of School Psychologists website for educators

NASP articles in Principal Leadership

NASP article by George DuPaul and George White, "An ADHD Primer"

ADHD IDENTIFICATION AND ASSESSMENT: BASIC GUIDELINES FOR EDUCATORS by George DuPaul

Angry and Aggressive Students by Jim Larson

Send comments on this story to ajehlen@nea.org.

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Published In

4-Oct-08

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