Who is to blame for boys struggling at school?

The “epidemic” of ADHD
Few discussion topics around the sandbox can spark a controversy more quickly than the diagnosis and treatment of attention-deficit/ hyperactivity disorder. The National Institutes of Health describe ADHD as a lifelong mental disorder that affects approximately 3 to 5 percent of the population. Although the disorder was largely unheard of before the 1950s, attention deficit medication in the United States is now a $2.7 billion industry. Plenty of people, including some  well-known research scientists, think that the widespread acceptance of ADHD marks a step forward in our understanding of human behavior. Plenty of other people, including some well- known research scientists, believe that the diagnosis and treatment of ADHD in this country is an example of junk science run amok. But there is one point about which both sides agree: There’s no medical test for ADHD. The identification of the disorder results from a series of highly subjective judgments.

Drug companies and Big Pharma–sponsored ADHD support groups insist the squishy diagnostic process means that ADHD is underdiag­nosed — that many people have the disorder but never get sensitive medical care and the proper treatment. But when you look at the na­tional data, one subgroup of the American public is getting identified and treated for ADHD at a truly astonishing rate: school-age boys.

Before you sit down to write me a nasty letter describing how ADHD is real and how ADHD meds helped your son, let me say this: I’m not pulling a Tom Cruise here. I’ve met very few responsible thinkers on this topic who believe that ADHD doesn’t exist at all. For some people — including some school-age boys — the arsenal of ADHD medications is nothing short of a godsend. That said, let’s take a harder look at who is being medicated for this disorder, who is doing the diagnosing, and why.

According to the Centers for Disease Control, in 2003, 14 percent of boys across the nation were identified as having ADHD by they time they reached their sixteenth birthday. And the percentage is continuing to grow. Between 2000 and 2005, the number of boys from birth to age nineteen who were being prescribed ADHD medication grew 48 per­cent. That such large numbers of boys are being diagnosed with a central nervous system disorder suggests two things: Either we are witnessing the largest pandemic in our country since influenza struck in the United States in 1918, or  school-age boys are being overidentified and overdiagnosed.

Why are boys in the crosshairs? Maybe it’s all about biology. We know that for complex biological reasons, boys are more vulnerable to genetic anomalies than girls. It’s possible, then, that they also might be more susceptible to as-yet-unknown environmental or chemical causes of the disorder. But other factors — including the higher academic ex­pectations, zero- tolerance policies, and shrinking of recess that we’ve been talking about — may be making boys’ behavior seem less normal and more pathological.

According to researchers who study dosage patterns, affluent white boys (who attend the schools where expectations for academic achieve­ment are most intense) and poor black boys (who attend underfunded, overcrowded schools with a high proportion of inexperienced teachers) are most likely to be identified as having attention problems and given medication. In two southeastern Virginia school districts — one poor and one affluent — a researcher at Eastern Virginia Medical School in Norfolk found that 20 percent of white elementary school boys, one in five, line up at nurses’ offices at lunchtime to take stimulants in order to get through the day. In a  follow-up and  as-yet-unpublished study, the researchers culled information from nurses and parents at three middle schools in the same area and found that an astonishing 38 percent of white boys were diagnosed with ADHD and 100 percent of them were taking medication for it. For boys, getting a neuropsychological workup or “getting tested” and trying out  attention-enhancing med­ication is becoming a perverse right of passage.

From daydreaming to Ritalin
Who does the diagnosing? What training do they have to determine which attention spans need enhancing and which do not? Let’s take a step back and see how it works.

In order for a child to be identified as having ADHD, the child has to have six of the following nine symptoms:

• Fails to give close attention to details or makes careless mistakes.
• Has difficulty sustaining attention.
• Does not appear to listen.
• Struggles to follow through on instructions.
• Has difficulty with organization.
• Avoids or dislikes tasks requiring sustained mental effort.
• Loses things.
• Is easily distracted.
• Is often forgetful in daily activities.

The child has to exhibit these symptoms in at least two out of three areas of life: home, social settings, or school. For  school-age boys, that usually means home and school. In order to elicit feedback from schools, doctors provide teachers with a checklist of behaviors: often fidgets with hands or feet, often runs about or climbs excessively, often has difficulty playing quietly, often fails to give close attention to details or makes mistakes in schoolwork. In a quiet moment between classes, a teacher reviews the behavior of one of her or his one hundred or so students and checks off “Never,” “Rarely,” “Sometimes,” “Often,” or “Always.” After talking to the parent and to the child and reviewing the checklist, psychologists and physicians interpret the checklist to deter­mine if a boy is “normal” or not.

How important is the teacher’s input? Bryan Goodman, a spokesman for Children and Adults with Attention Deficit/Hyperactivity Disorder (CHADD), a support group funded in part by drug companies that make popular attention-enhancing drugs, says, “Our position is that only medical professionals should make a diagnosis for ADHD. But teachers do provide crucial information that parents can then take to medical professionals.”

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