You want an A or B on your report card, just ask Mommy or Daddy for a little pill....
CANTON, Ga. â When Dr. Michael Anderson hears about his low-income patients struggling in elementary school, he usually gives them a taste of some powerful medicine: Adderall.
The pills boost focus and impulse control in children with attention deficit hyperactivity disorder. Although A.D.H.D is the diagnosis Dr. Anderson makes, he calls the disorder âmade upâ and âan excuseâ to prescribe the pills to treat what he considers the childrenâs true ill â poor academic performance in inadequate schools.
âI donât have a whole lot of choice,â said Dr. Anderson, a pediatrician for many poor families in Cherokee County, north of Atlanta. âWeâve decided as a society that itâs too expensive to modify the kidâs environment. So we have to modify the kid.â
Dr. Anderson is one of the more outspoken proponents of an idea that is gaining interest among some physicians. They are prescribing stimulants to struggling students in schools starved of extra money â not to treat A.D.H.D., necessarily, but to boost their academic performance.
It is not yet clear whether Dr. Anderson is representative of a widening trend. But some experts note that as wealthy students abuse stimulants to raise already-good grades in colleges and high schools, the medications are being used on low-income elementary school children with faltering grades and parents eager to see them succeed.
âWe as a society have been unwilling to invest in very effective nonpharmaceutical interventions for these children and their families,â said Dr. Ramesh Raghavan, a child mental-health services researcher at Washington University in St. Louis and an expert in prescription drug use among low-income children. âWe are effectively forcing local community psychiatrists to use the only tool at their disposal, which is psychotropic medications.â
Dr. Nancy Rappaport, a child psychiatrist in Cambridge, Mass., who works primarily with lower-income children and their schools, added: âWe are seeing this more and more. We are using a chemical straitjacket instead of doing things that are just as important to also do, sometimes more.â
Dr. Andersonâs instinct, he said, is that of a âsocial justice thinkerâ who is âevening the scales a little bit.â He said that the children he sees with academic problems are essentially âmismatched with their environmentâ â square pegs chafing the round holes of public education. Because their families can rarely afford behavior-based therapies like tutoring and family counseling, he said, medication becomes the most reliable and pragmatic way to redirect the student toward success.
âPeople who are getting Aâs and Bâs, I wonât give it to them,â he said. For some parents the pills provide great relief. Jacqueline Williams said she canât thank Dr. Anderson enough for diagnosing A.D.H.D. in her children â Eric, 15; Chekiara, 14; and Shamya, 11 â and prescribing Concerta, a long-acting stimulant, for them all. She said each was having trouble listening to instructions and concentrating on schoolwork.
âMy kids donât want to take it, but I told them, âThese are your grades when youâre taking it, this is when you donât,â and they understood,â Ms. Williams said, noting that Medicaid covers almost every penny of her doctor and prescription costs.
Some experts see little harm in a responsible physician using A.D.H.D. medications to help a struggling student. Others â even among the many like Dr. Rappaport who praise the use of stimulants as treatment for classic A.D.H.D. â fear that doctors are exposing children to unwarranted physical and psychological risks. Reported side effects of the drugs have included growth suppression, increased blood pressure and, in rare cases, psychotic episodes.
The disorder, which is characterized by severe inattention and impulsivity, is an increasingly common psychiatric diagnosis among American youth: about 9.5 percent of Americans ages 4 to 17 were judged to have it in 2007, or about 5.4 million children, according to the Centers for Disease Control and Prevention.
The reported prevalence of the disorder has risen steadily for more than a decade, with some doctors gratified by its widening recognition but others fearful that the diagnosis, and the drugs to treat it, are handed out too loosely and at the exclusion of nonpharmaceutical therapies.
The Drug Enforcement Administration classifies these medications as Schedule II Controlled Substances because they are particularly addictive. Long-term effects of extended use are not well understood, said many medical experts. Some of them worry that children can become dependent on the medication well into adulthood, long after any A.D.H.D. symptoms can dissipate.
According to guidelines published last year by the American Academy of Pediatrics, physicians should use one of several behavior rating scales, some of which feature dozens of categories, to make sure that a child not only fits criteria for A.D.H.D., but also has no related condition like dyslexia or oppositional defiant disorder, in which intense anger is directed toward authority figures. However, a 2010 study in the Journal of Attention Disorders suggested that at least 20 percent of doctors said they did not follow this protocol when making their A.D.H.D. diagnoses, with many of them following personal instinct.
On the Rocafort familyâs kitchen shelf in Ball Ground, Ga., next to the peanut butter and chicken broth, sits a wire basket brimming with bottles of the childrenâs medications, prescribed by Dr. Anderson: Adderall for Alexis, 12; and Ethan, 9; Risperdal (an antipsychotic for mood stabilization) for Quintn and Perry, both 11; and Clonidine (a sleep aid to counteract the other medications) for all four, taken nightly.
Quintn began taking Adderall for A.D.H.D. about five years ago, when his disruptive school behavior led to calls home and in-school suspensions. He immediately settled down and became a more earnest, attentive student â a little bit more like Perry, who also took Adderall for his A.D.H.D.
When pubertyâs chemical maelstrom began at about 10, though, Quintn got into fights at school because, he said, other children were insulting his mother. The problem was, they were not; Quintn was seeing people and hearing voices that were not there, a rare but recognized side effect of Adderall. After Quintn admitted to being suicidal, Dr. Anderson prescribed a week in a local psychiatric hospital, and a switch to Risperdal.
While telling this story, the Rocaforts called Quintn into the kitchen and asked him to describe why he had been given Adderall.
âTo help me focus on my school work, my homework, listening to Mom and Dad, and not doing what I used to do to my teachers, to make them mad,â he said. He described the week in the hospital and the effects of Risperdal: âIf I donât take my medicine Iâd be having attitudes. Iâd be disrespecting my parents. I wouldnât be like this.â
Despite Quintnâs experience with Adderall, the Rocaforts decided to use it with their 12-year-old daughter, Alexis, and 9-year-old son, Ethan. These children donât have A.D.H.D., their parents said. The Adderall is merely to help their grades, and because Alexis was, in her fatherâs words, âa little blah.â
âWeâve seen both sides of the spectrum: weâve seen positive, weâve seen negative,â the father, Rocky Rocafort, said. Acknowledging that Alexisâs use of Adderall is âcosmetic,â he added, âIf theyâre feeling positive, happy, socializing more, and itâs helping them, why wouldnât you? Why not?â
Dr. William Graf, a pediatrician and child neurologist who serves many poor families in New Haven, said that a family should be able to choose for itself whether Adderall can benefit its non-A.D.H.D. child, and that a physician can ethically prescribe a trial as long as side effects are closely monitored. He expressed concern, however, that the rising use of stimulants in this manner can threaten what he called âthe authenticity of development.â
âThese children are still in the developmental phase, and we still donât know how these drugs biologically affect the developing brain,â he said. âThereâs an obligation for parents, doctors and teachers to respect the authenticity issue, and Iâm not sure thatâs always happening.â
Dr. Anderson said that every child he treats with A.D.H.D. medication has met qualifications. But he also railed against those criteria, saying they were codified only to âmake something completely subjective look objective.â He added that teacher reports almost invariably come back as citing the behaviors that would warrant a diagnosis, a decision he called more economic than medical.
âThe school said if they had other ideas they would,â Dr. Anderson said. âBut the other ideas cost money and resources compared to meds.â
Dr. Anderson cited William G. Hasty Elementary School here in Canton as one school he deals with often. Izell McGruder, the schoolâs principal, did not respond to several messages seeking comment.
Several educators contacted for this article considered the subject of A.D.H.D. so controversial â the diagnosis was misused at times, they said, but for many children it is a serious learning disability â that they declined to comment. The superintendent of one major school district in California, who spoke on the condition of anonymity, noted that diagnosis rates of A.D.H.D. have risen as sharply as school funding has declined.
âItâs scary to think that this is what weâve come to; how not funding public education to meet the needs of all kids has led to this,â said the superintendent, referring to the use of stimulants in children without classic A.D.H.D. âI donât know, but it could be happening right here. Maybe not as knowingly, but it could be a consequence of a doctor who sees a kid failing in overcrowded classes with 42 other kids and the frustrated parents asking what they can do. The doctor says, âMaybe itâs A.D.H.D., letâs give this a try.â â
When told that the Rocaforts insist that their two children on Adderall do not have A.D.H.D. and never did, Dr. Anderson said he was surprised. He consulted their charts and found the parent questionnaire. Every category, which assessed the severity of behaviors associated with A.D.H.D., received a five out of five except one, which was a four.
âThis is my whole angst about the thing,â Dr. Anderson said. âWe put a label on something that isnât binary â you have it or you donât. We wonât just say that there is a student who has problems in school, problems at home, and probably, according to the doctor with agreement of the parents, will try medical treatment.â
He added, âWe might not know the long-term effects, but we do know the short-term costs of school failure, which are real. I am looking to the individual person and where they are right now. I am the doctor for the patient, not for society.â