ADHD drugs prescribed to failing students

Imagine the elementary school student who tries his best, who does her homework, who stays out of trouble. The one who still has to come home to parents with a lousy report card because of an inadequate schooling environment.

When crumbling schools fail and students are left struggling in the lurch, what do we do? Fix the system or fix the kid? Many would say that we need institutional changes to better our education in this country. But some would say the opposite.

An article published by The New York Times on October 9, 2012 titled “Attention Disorder or Not, Pills to Help in School” describes a recent trend of doctors using medication as an intervention for students falling behind in broken schools.

The drugs of choice: ADHD medications. Drugs like Ritalin and Adderall can help children who have attention deficit hyperactivity disorder (ADHD) focus better in general, and particularly in a classroom setting.

But children who actually have ADHD are not the only patients being prescribed these medications. Rather, some pediatricians, namely one in Cherokee County, Georgia, might falsely give an ADHD diagnosis in order to have a “healthy” child use these drugs to augment a poor performance in school.

This practice, though not highly prevalent, raises questions of efficacy, safety, and morality.

First, will these drugs even work on a child who does not have ADHD?

“If you don’t have it, I don’t think it works very well,” Michael Johnston, the Senior Vice President and Chief Medical Officer of the Kennedy Krieger Institute in Baltimore, said.

“My view over the years has been that the people who benefit are the ones who have the specific syndrome of impulsivity and hyperactivity… The ones that have that tend to get the benefit of being able to focus in the classroom.”

Johnston, who is also a professor of neurology and pediatrics at the Hopkins School of Medicine, went on to clarify that ADHD medication can help children focus, but does not stimulate learning. Additionally, he pointed out that proper dosage is an incredibly important factor as performance can suffer when too much of the drug is taken.

Johnston describes that the American Psychiatric Association gives diagnosis guidelines for ADHD rather clearly in the Diagnostic and Statistical Manual of Mental Disorders. The DSM-IV states that inattention must be more severe than what is considered normal, and that symptoms must be seen in a minimum of two settings — at home and at school, for example.

Margaret Moon, an assistant professor in the Division of Pediatrics and Adolescent Medicine at the Berman Institute of Bioethics, disagrees with Johnston, saying that the criteria for an ADHD diagnosis are relatively loose and that she understands the pressures doctors are under to help patients in any way possible. “It’s pretty clear to everybody that it does help,” she said.

Neurons in the brain release dopamine and norepinephrine, chemicals called “neurotransmitters,” which have an organizing effect on the cortex ultimately increasing attention. Dopamine typically relates to movement behaviors, motivation and reward whereas norepinephrine is related to attention.

ADHD drugs like Adderall contain amphetamines, which temporarily block the reuptake of these neurotransmitters across neuronal synapses. This enables the chemicals to have a more concentrated effect over a longer period of time, thereby increasing attention. Though most ADHD drugs are stimulants, there are currently three non-stimulants on the market.

The side effects, though typically not severe, can be loss of appetite and sleeping issues, both of which are legitimate concerns when prescribing medications to elementary-age students. Johnston points out, however, that these side effects are obvious and would normally be noticed by parents or teachers, allowing a change in medication tailored to the patient.

Johnston compares the medications to insulin, saying that they are very effective and should only be used when needed. “When it works, it really works,” he said.

For Ishan Dasgupta, a Research Program Coordinator at Berman and a Hopkins alumnus, it’s not as much a matter of the effectiveness of prescribing these medications to children without ADHD as the moral implications of the prescription. “From an ethics standpoint, it gets on sort of shaky ground,” he said.

Dasgupta actually takes a positive stance on high school and college students using drugs like Adderall as a tool to “bridge the gap” between difficult classes and a student’s abilities. However, he gets tripped up with this new case by the fact that these are elementary school children. “The child almost doesn’t know better. It’s setting them up to believe they have an affliction they don’t really have,” Dasgupta said.

Dependency is his primary concern; when young students are given this boost, how will they develop the critical academic skills they need? “It really troubles me to see doctors prescribing drugs as a short-cut.”

Moon echoes this sentiment, cautioning dependency on artificial crutches like these. “If you’re relying on an enhancement, just remember that you have the rest of your life to face.”

While Dasgupta suggests that the long-term effects of using these drugs remain unknown, Johnston says that the rates of addiction are not any higher for kids with ADHD who may be taking the drugs over a long period of time than with “healthy” children. ADHD medications are a controlled substance, however, because they contain dexamfedamine, which causes weight loss. Concern over adults abusing the drugs also exists.

Dasgupta sees these prescriptions as the latest symptom of “over-medicalization” in our society, where even eyelash length has become a medical issue. Aside from New Zealand, the US is the only developed country in which direct advertising of drugs is legal. Additionally, doctors are compensated by the number of patients they see and the number of diagnosis they make, though this is beginning to change under Obamacare.

Interestingly, prescription rates for children fell by seven percent between 2002 and 2010, according to “Trends of Outpatient Prescription Drug Utilization in US Children, 2002-2010,” published online in Pediatrics in June 2012. Cold and allergy medicine use did decrease, while ADHD medication prescriptions rates have risen by 46 percent.

According to parent reports collected by the Centers for Disease Control (CDC), the ADHD rate in the country is 9.5 percent and is increasing three percent each year.

Moon hypothesizes that the prevalence of ADHD probably does not actually fluctuate greatly, but rather that teachers are noticing and reporting more and more problematic behavioral patterns caused by distressed school systems.

Is this, as Dasgupta said, just throwing drugs at a structural problem?

According to the CDC report calculated in 2005 dollar value, the societal “cost of illness” for ADHD is around $36 to $52 billion per year when using a five precent prevalence rate. This equates to plus or minus $15,000 dollars per person.

The CDC also details that the parent-reported diagnoses are at the highest rates for children covered by Medicaid.

If this diagnosis rate is in fact increasing from false diagnoses for trouble in school, is this where the money should be going? Perhaps fixing and improving education infrastructure also needs to be contemplated in the realm of worthwhile investments.