It looks as though I am going to be revising my Future Imperfect manuscript for publication, and one thing I plan to add is a chapter on mind drugs: Recreational, performance enhancing, and controlling. I have accordingly started looking into the current controversy over Ritalin and related drugs for controlling ADHD. In doing so, I was struck by a puzzle which nothing I have so far come across seems to deal with.
Currently, something like five to twenty percent of children are diagnosed with ADHD and those so diagnosed are widely claimed to be unable to function in a classroom without medication. Fifty years ago, neither Ritalin nor ADHD diagnoses existed—and classrooms functioned, judging by results, at least as well as they do now. That raises an obvious puzzle, to which I can see at least four possible solutions:
1. The rate of ADHD has drastically increased. While that is not impossible, there seems to be no plausible explanation for such an increase. The only clear evidence on causation is that ADHD is in part genetic.
2. ADHD is in large part a bogus problem—the view of many of the critics of Ritalin use. Teachers get parents to drug their kids because it's less trouble than dealing with normal kids undrugged. This seems to contradict the anecdotal evidence from lots of parents, who report large improvements in their children's behavior as a result of the drugs—but that might mean that one percent of children really have the problem and the rest don't.
3. What has changed is not the prevalence of ADHD but the environmental requirements on kids. The same child who is functional in many other environments may be a serious problem if he asked to sit still and be quiet for most of five hours a day—as many of us would be. The point was made by one mother who commented that it was odd that her child only seemed to have ADHD nine months of the year—he was fine, undrugged, during the summer. The problem with this explanation is that, fifty years ago, schools had classrooms in which kids had to sit and be quiet.
4. Fifty years ago, undiagnosed ADHD kids were a serious problem, but while we have largely solved that problem with drugs, other school problems have gotten worse, which is why, on net, things are no better now than then. That seems inconsistent with at least the stronger claims about just how much of a problem ADHD is in the classroom and how common it is.
As these brief comments suggest, I don't have a clear answer to the puzzle. Suggestions? Pointers to webbed discussions that might help?
26 comments:
Could there be a #5? Kids have not changed, but adult expectations of them have. 50 years ago impish, mischeivous behavior by kids (particularly boys) was considered normal. Today it is a symptom. That doesn't mean that ADHD is not a real problem - just that it is way over diagnosed, and although drugged up kids may behave better, that doesn't mean there was anything really wrong with them in the first place.
My memory of school is that the most disruptive pupils tended to be the ones most likely to play truant. (I blogged about it here, in fact.)
Is there any evidence that schools were more likely to turn a blind eye to truancy 50 years ago?
My own guess, for which I have no evidence, is that the rate of ADHD is much as it was 50 years ago, but that there are lots of ways of dealing with it. In the days when a troublemaker was soundly thrashed, it provided a little extra motivation to teach yourself how to focus. When the people who were highly respected by society were honest hard workers and there was no way to just coast through life without supporting yourself, the value of actually trying to achieve something in school might have been more obvious. (Jeez, I sound like I'm 80 years old.) How lucky for kids of today that a little medication obviates the need for crass fear of consequences.
People coped with lots of mental disfunction in the old days that are medically tractable today. Probably only a small fraction of them actually failed to cope, or would actually fail to cope today, but that doesn't mean lots more than that can benefit to a lesser degree.
I guess this sort of straddles the fence between #2 and #3. Probably not all kids diagnosed would really be unable to function unaided, but the environment has changed, too -- nobody wants to go back to the days when the other forces I mentioned could be brought to bear.
Judging from preliminary research using MRI scans, ADHD brains display different patterns of activity from normal ones and become more like normal brains when on drugs like Ritalin or varius SSRI meds.
That being said, I have never run across a child who was diagnosed using an MRI scan.
The survey method of reporting used by most pediatricians, in my view, unscientific and creates a lot of false labels and misses not a few kids who actually have a mild case of ADHD and might benefit from a low dosage of a drug coupled with behavioral techniques to teach self-control and enhance concentration
Nor do I think teachers or schools " push" meds today any more than do exasperated parents who approach schools inquiring about ADHD and wanting an evaluation for a 504 plan. That was probably true about a decade ago but schools have found that these drugs are no panacea, and are counterproductive if the child does not have ADHD (it is simply "speed" lite in that case)
What was the difference with fifty years ago ? Since most cases of ADHD are mild and are positively affected by behavioral therapy, it was probably the higher standards of school discipline, parenting and general adult supervision compared to today and fewer fatherless families.
50 years ago, kids spent a LOT less time in school. Kids spent a heck of a lot more time running off that excess energy. What do a lot of kids spend their afternoons doing? Also there are environmental and dietary changes to consider. It isn't a single-cause difference.
As an adult with ADD (note no H, I tend to space out) and especially a girl in school where such typically ADD behaviour was seen as either good (I can look like I'm paying attention) or just plain dreamy and disorganized, I can say quite confidentally in all but extreme cases the drugs are just a temporary pnacea until the behaviour moderation kicks in.
I haven't had an MRI, but I did have an EEG whch measures brain wave patterns. These were seen as normal at the time, but we know so much more now.
What helps me? More protein, more exercise. Caffiene is not a stimulant to me at all.
And I'm not disabled. I just do things differently than a lot of people.
Ritalin is good, but marijuana is bad... hmm... who benefits from this government protected racket? :-)
#2 is written a bit simply. Surely there is a spectrum of this kind of behavior, some improvable with drugs. It is not just 1% "problem" and the rest "normal." Fifty years ago the problem was the child's not the school's and these children were not necessarily in the classroom.
Schools fifty years ago ( or even 30 years ago) did not have so much pressure to keep all kids in the classroom. Bad behavior, i.e. disruptive or dangerous, not merely dreamy, was not a handicap and was punished. That meant more hours in the principal's office, expulsion or truancy and thus higher standards of behavior in the classroom. The kids in class saw real consequences for misbehavior and had a real incentive to try to behave well in class if they could. Where I went to school they didn't thrash anyone although I suppose some parents may have.
I remember several kids from my youth who were chronically in trouble; today they are reasonably successful adults. My wife, who taught for many years, had to "manage" similar kids within her classroom rather than throwing them out when they behaved badly. Many of these were medicated in some way which did improve their behavior, more or less.
I know many long time teachers and they all agree that parents in general are less supportive of high standards of behavior in the classroom. My guess is that these parents are more likely to look for a "medical" explanation of their kids behavior.
So, my #5 is that we used to mange problem behavior through the child's will power by creating serious consequences for poor behavior. The consequences included removal from the classroom so the failures of "management" were not as visible.
On an evolutionary timeline, civilization is a pretty recent development--let alone the idea of forcing young humans to sit in desks for hours on end.
Rather than trying to medicate children into the system, perhaps we should consider the changing the system.
I too recently saw something on recess being cut -- maybe on Pharyngula. Gotta make time for testing, after all. I could see that and changes in afterschool physical activity being responsible.
I wonder how the average kid's day of today compares to that of 50 years ago. How much time in school, how much time running around outside, how much on sedentary activities (videogames now, reading then), etc? Perhaps there's a limit on the number of hours in a day that a kid can sit still and more of those hours are consumed outside of school than used to be? Wild speculation and no data; I'm just raising the question.
Your #2 skirts a logical fallacy. Just because someone does something better or feels better on a drug, does not mean they suffer an illness or chemical deficiency. That is to say, it might be that some subpopulation has a variant body chemistry which allows them to metabolize, e.g., ritalin as a performance enhancing drug, but that they are able to function normally without it.
I would add #5: Fifty years ago, children who had sufficient difficulties in schools were expelled or dropped out, and that was both socially acceptible (to their parents) and social viable (for them). There were trades, factories and farms to provide work for people who were not academically talented -- or even academically adequate.
Today, a far greater percentage of the population aspires to college; a college degree has socially taken on what I understand to have been the credentialling role of a high-school diploma fifty years ago (i.e. demonstrating basic adequacy as an employee); there is far greater pressure (socially, economically) both on the students to stay in school and on the school to retain the students.
I suspect that 50 years ago, those "difficult" students would have been labeled as "bad kids" early in their schooling, and washed out by 8th grade.
Wow, DFriedman posts a question that I (feel I) know the answer to, and not the other way around. I'm positively honored!
So, one important thing I might add is that ritalin (along with adderall, or for that matter, methamphetamine, or cocaine) -- the “stimulant” class of drugs, though we mean something different than caffeine here -- make people "focus" by virtue of their similar actions on the brain. These effects are universal, not just in people tagged with ADHD (which is why ritalin, but more so adderall (more fun, works better), is sold on college campuses and taken on cram days before tests). On these sorts of substances, monotonous activity becomes somehow rewarding -- speed addicts cleaning the house spotless, and so forth. Why does monotonous activity turn interesting? These drugs are essentially putting you in the state you are in while fascinated by a good book. The areas associated with reward (limbic system) and focus (pre-frontal cortex) are activated by stimulants, say imaging studies. But if you’re not convinced (and one should be very skeptical of this stuff), you can test this out for yourself if you like: take methamphetamine and see how much work you get done (and how u feel introspectively: "driven.")
(I might add that these drugs have other effects, such as they get you "high," which also tends to make people more agreeable. I might also add that we tolerate to their effects in time, which is a likely reason "ADHD" hasn't been "cured" by daily administration of these drugs. – the better way to use these drugs, if at all, is acutely, before a big test, such as they are used by people in the “free market” on campus.)
So, we've got these drugs that will tame anyone, and make them more productive generally (in the short-term anyway). But why do we need to prescribe them? I think the likely story is environmental. Namely, a lot of students don't really see the purpose of memorizing the periodic table, and thus find it unpleasant. The system doesn’t really adapt to them in the way one’s boss at work might try to accommodate you and keep you productive. Perhaps a better example: give my ADHD-diagnosed, poor-performing(-in-school) cousin a fun game like Resident Evil and they sit still and focus and learn how to essentially complete a very complex puzzle game. This explains why ADHD is mostly a school-related phenomenon.
So lastly, I might add that I've been variously diagnosed with ADHD, depression, bipolar, asperger's, variously learning disabilities -- i have these diagnoses because doctors gave them to me and because my parents brought me to these doctors looking for solutions to problems I was having. But diagnosing someone with any of these is a very inexact science. And for what it’s worth, they bring us no close to solutions. (The answer is always “therapy”)
OK, that post was a bit garbled, but I think I got my point across. Blame my learning disability otherewise.
Alcibiades
Chemgasm.com
Parents face much less social stigma by medicating their child while the expectations of both teachers and other adults for children (especially boys) to be quiet and well behaved has gone up. Drug treatment is much more available as ADD is diagnosed more often and psychiatrists more readily suggest drug treatment.
Take a look at Thomas Szasz and Stanton Peele's stuff. It's a lot about how illnesses are socially constructed: it doesn't mean they're not real, it just means a lot of what the illness is, how we think about it, how symptoms appear, is mediated by other stuff. Szasz stuff is a bit dated.
Another (partial) hypothesis, a variant on your 3:
Although schools have not changed significantly in the last 50 years, the general environment has, a lot. Specifically, the quality and variety (and cheapness, hence availability) of entertainment products has gone way up. As I posited in my pamphlet on the art of storytelling, what we face in a modern audience is not "short attention span", but "low boredom tolerance". A well-made movie can keep an audience rapt for two uninterrupted hours or longer. But today's consumers are much more able (and likely) to "change the channel" when bored. Hence, they have less experience with tolerating boredom.
Modern methods of education were evolved in a much more primitive media environment, with much less competitive pressure. People were used to being bored some of the time. A Saturday at the movies would be two features, a newsreel and some cartoons -- not all of which would be interesting to any given audience member. If you had a television at all, you didn't have very many choices in terms of channels. Being used to that ocassional boredom, the boredom of school was comparitively bearable.
Now, however, people essentially never have to be bored (on their own time). I'm far from rich (compared to my social network, anyways), and I own literally dozens of unread books I want to get to eventually, and similar quantities of DVDs and videogames. That's just the items that are physically in my house right now, overlooking the vast quantities of entertainment that are available fast and cheap over the internet. Children growing up in this environment have no great incentive to build up boredom-tolerance skills before they encounter school.
Of course, one can argue that the real fault here is in the fact that the schools are boring. There is no inherent reason why they must be, and many arguments that schools would actually be more effective if they were more interesting.
A few ideas:
For environmental:
It sounds like schools may have been stricter back in the day. Perhaps fear of physical punishment was enough to get ADHDers to hide their symptoms better, and drugs are the replacement.
Diet. I was just talking with a nanny who was telling me about a "very serious" ADHD case she was working with. She said that the boy couldn't stick to one activity for more than a few minutes, but also noted that he ate an exceptional amount of sugar, which would probably drive most people to jumping up and down. Perhaps the rise in ADHD diagnosis is in part related to the rise in average weight?
I'm not sure how much ADD plays into the increased stats. I'm pretty certain that its historically underdiagnosed, myself being a case of it, but is being recognized more these days I think. I was not a disruption to classrooms, but an annoyance to teachers none the less because I spaced out, fell asleep, and/or drew pictures instead of paying attention to the teacher, and I actually almost got held back a grade because of my said behavior issues.
If ADhD is recessive or some other genetic thing with similar effect, the possibility of AD(h)Ders being attracted to each other, and more likely to get together with the way it is getting increasingly easier to meet a wider selection of people could produce more of them. How uniform is the increase through the country? Do we have more ADhDers moving to coasts and/or big cities?
I think it's pretty common to have a range of symptoms of some problem (or personality trait) like ADHD or depression. If you haven't got any useful treatment for it, then most cases don't get diagnosed (what's the point) and everyone who has it does their best to live with it. If your treatments are dangerous or otherwise expensive, then only really serious cases get treated. If your treatments are fairly cheap (in terms of risk, especially), then lots of people get treated, probably including some who didn't really need the treatment.
That's separate from the question of whether ADHD needs medication, or whether it's just one of the many personality/mental traits that get more-or-less randomly assigned to children, because having descendents capable of many different strategies for making a living leads to having more descendants in a world where things change pretty often.
Response posted to http://syndicated.livejournal.com/daviddfriedman/18635.html
I agree with the general tenor of many of the previous comments. My view is simple: the cost of disruptive behavior has gone down, so we see more of it. I do not believe children have changed (i.e. greater prevalence of ADHD), nor to I believe that the school environment has changed (if anything, “active” learning is more in vogue today). However, the tools available to teachers and others to control behavior have changed (elimination of corporal punishment, etc.). Consequently, more children do not “function” in the classroom because the incentives to do so have changed.
The “price” of ADHD behavior has fallen and the quantity has increased. Now, unwilling to raise the “price,” we attempt to shift the demand curve: medicate to reduce the “benefit” of ADHD behavior.
I'm wondering if ADHD is the result of examining children instead of ignoring them.
-=-The problem with this explanation is that, fifty years ago, schools had classrooms in which kids had to sit and be quiet.-=-
Fifty years ago, there were two recesses and a long lunch-hour with playtime. Fifty years ago, elementary school classrooms had singing, and art, and things that involved standing up and moving (spelling bees, acting out verses they were having us memorize, speaking as someone who went to school not 50 years ago, but 47 years ago).
Might be part of it. One more little clue for you.
1) The rate of ADHD has not increased so much as access to mental health. As with any new disease, rates of occurance increase as more health workers become aware of the problem and as better testing measures become available. That said...
2) I believe that ADHD is, in large part, a bogus problem. In the early 80s it was widely misdiagnosed(my parents were given the option of taking me to a specific doctor for a Ritalin prescription or taking me out of school) and while some of the more egregious uses of an ADHD diagnosis have fallen out of use, it is still often times used as a label for difficult kids. Teachers and administrators have more children to deal with, less time to deal with them, and often times less interest in the outcome of their students. It is far easier to deal with a drooling zombie than a child who asks "why?" every ten seconds. The problem is only compounded when you begin to consider the number of aging teacher and admins who are just waiting for their pension plan to kick in.
More importantly, there is a disturbing trend in American schools to treat children who are mentally or emotionally abnormal as a burden which must be brought to the norm. As a student who was both learning disabled and of significantly above-average intelligence I saw the ways that both groups of abnormal students were treated. The brilliant children were cloistered away in different schools, kept away from the general population and constantly told how lucky they were. The less fortunate students were similarly segregated, and insulated from anything that might be considered a challenge. In this way, classes were able to be held for these students in a manner that more traditional administrators could understand: teach to the lowest common denominator for the idiots, give the eggheads calc in eighth grade, forget that these students are here because of significant individual differences. I can remember several instances in my early education when I went from an enrichment class that was reading Shakespeare only to have my next 45 minutes taken up by remedial phonics. American schools are simply neither equipped nor interested in dealing with any kind of individual difference in students. To quote John Lennon "[t]hey hate you if you're clever and they dispise a fool."
50 years ago students that were different either managed to find a coping mechanism or were drummed out. Those are no longer options today, so schools look for a way of making the freaks more manageable.
I don't necessarily agree with the feeling that ADHD is becoming more common because the conseqeunces for being disruptive have been reduced. 50 years ago a disruptive student might have been slapped across the knuckles with a ruler, but I think it is unlikely that two boys who got in a fist fight would be lead away in handcuffs to be charged as adults or a maladjusted loner would come home to find his room being searched by police in the wake of a school shooting on the other side of the country. 50 years ago I doubt that expulsions for first offenses were the norm. If anything, consequences for disruptive behavior have increased as zero-tollerance has become more common. It is just another example of school administrators excising any factors which deviate from the norm.
The prevelance of ADHD diagnosis is a symptom of schools seeking easy solutions to complex problems. A student who is a pain in the ass can be dosed with Ritalin, Adderal, or any of the other drugs that are often used to make student more tractible(such as tricyclic antidepressants) much more easily than they can be conditioned to behave.
The percentage of students completing their high schooling has probably increased over the years, as Siderea said.
I can't find historical figures, but in modern Australia around 85% of students finish their high school (year 12), and very few leave before year 10.
I imagine that it was reasonably common 50 years ago for students to leave in early secondary years to enter the workforce. The students who remained would probably be the ones who tended to fit into the classroom environment well, whereas 'troublemakers' would be more likely to drop out.
I think this is a very important factor.
The Biggest Scam which creates harm to the Individuals that HAVE ADHD, Including the ADULTS - (not only children have it) is that people ignore the fact that Today the ADHD is considered one of the best researched disorders in American History and the overall data on its validity are far more compelling than for most mental disorders and even many medical conditions," according to the American Medical Association Council on Scientific Affairs.
Please let us not forget that Dr. Baughman RETIRED in 1993, he was a CHILD Neurologist – so many advances have occurred not only in Science but technology, that allows us to be able to learn more about it.
Now, correct me if I am wrong, but has Dr Baughman been PERSONALLY involved in ANY randomized controlled scientific meta studies, clinical trials or research, based upon ADHD? In Any studies that have been acknowledged by the Medical boards? Especially in the past 10 Years, with the advancements of science and technology? And especially with Adults who have the disorder.. ADULTS who can articulate, and express their experiences better than children! Adults who can express their considerable frustrations and pain dealing with Untreated ADHD?
Noted Quote -
Although he is frequently cited by CCHR and has written articles in support of Applied Scholastics, Dr. Baughman is generally regarded as an unrepresentative and ill-informed voice on learning disabilities. The National Alliance for the Mentally Ill (NAMI) told the Congressional Committee on Education and the Workforce in a letter of September 29, 2000 that Dr. Baughman "represent[s] fringe opinions about the disorder and about psychiatry." His position is certainly at odds with mainstream research and ignores the findings of a huge amount of research from around the world.
Yes, indeed, the biggest fraud are articles and the individuals who really haven’t invested the time researching the disorder with individuals (ADULT) individuals who suffer from it day to day. and whom can share their Life Experience.
That indeed is a disservice to the public
He has been noted to say that scientific research has yet to prove him wrong.. i say that the Complete OPPOSITE is true. P.S, has anyone noticed also or is it just me, but it is very difficult to respond to many if not most of the sites that present these uninformed, personal prejudices? and if you do get to post, very rarely would you see your responses as they are being censored?
Especially noted by many of the "peers" and friends of Baughman? It does make one wonder.
from Living Experience
My name is Nikki Hughes and i would like to show you my personal experience with Ritalin.
I am 51 years old. Have been on Ritalin for 9 years now. I began taking it for depression after my marriage ended, and also in a misguided attempt to lose weight! I lost about 15 pounds at the beginning, had tons of energy, felt great...but the weight loss stopped within a few months.. I currently feel focused and motivated after I take it and am able to get a lot done. As well as the generic ritalin, I take 6 - 12 Tylenol 1 tablets a day. I know how bad this is, but can't seem to stop for more than a few days. The last nine years seem to be a blur...it's like I have lost those years....I hardly remember anything about them. I find this sad and frightening. I take what my doctor prescribed: three 10mg. tablets a day. I have tried many times to completely get off this drug but I now realize that I am truly addicted to it. If I stop taking it for more than one day I become extremely depressed and have very negative, hopeless thoughts and ideas.
I have experienced some of these side effects-
very irritable when it wears off; sometimes difficult to fall asleep, memory loss, hear music in my head that won't stop.
I hope this information will be useful to others,
Nikki Hughes
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