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My eight-year-old son has trouble paying attention in school. He’s always been very active and easily bored. The school had him evaluated by the school psychologist, who thinks he has ADHD. They are pressuring me to take him to a doctor and get him on stimulant drugs and even threatened to call Child Protective Services if I don’t agree to it. I feel very uncomfortable with this, but they seem to think it’s the only answer. What should I do?
Reply from Steve McCrea, MS
Commonly, children are identified as “ADHD” by their teachers or school staff. It is also very common that parents and the children themselves see things differently from the school. Unfortunately, disagreeing with school personnel can be quite intimidating for many parents, even if schools are relatively friendly in their approach.
First off, a public school cannot force you to give psychiatric drugs to your child or threaten them with expulsion or “special classes” if you choose not to. This was written into the federal Individuals with Disabilities Education Act (IDEA), the nation’s special education law. So don’t be afraid to just say “no” if you don’t want to exercise this option. It is your decision as a parent and they need to respect your right to decide.
Know Your Rights
It is extremely inappropriate for the school to threaten CPS involvement for this reason, and if they have done so, I’d consider consulting with a special education attorney to see what legal action can be taken. (Most will do a phone consult for free. If that’s not the case, and you can’t afford an attorney, there are often special education advocacy groups who are happy to help out.) I would certainly not hesitate to let them know that you are deeply offended that they would use such tactics to try to pressure you into doing what they want. They will most likely quickly backpedal and assure you they had no such intention, but speaking those words out loud can be very powerful in letting them know you are not to be intimidated.
The standard for removing children from a parent’s legal custody is that the parent presents an immediate risk of harm to the child. As you will see below, research has yet to determine there is any long-term benefit to stimulant treatment, so to claim that the child is in some kind of immediate danger is fairly absurd and ought to be dismissed by any competent judge. Still, it may be worth consulting with a juvenile court attorney for parents and/or children in your area to see what the attitude toward this kind of case is in your court’s jurisdiction.
Separate Fact from Opinion
Parents generally have good questions about diagnosis and treatment that schools may not be equipped to answer: How do you know my child “has ADHD” in the first place? Can I say “no” to stimulants even if you want me to try them? What are the adverse effects of these drugs? What are the long-term effects of drug treatment? What other things can we try?
I’ll try to answer most of these questions below.
It is important to start by noting that “ADHD,” or Attention Deficit Hyperactivity Disorder, is not something that anyone can diagnose objectively. The criteria for “ADHD” are a list of behavioral traits that are contained in the DSM diagnostic manual that mental health professionals use. These include subjective measures such as, “often has trouble holding attention on tasks or play activities,” “often does not seem to listen when spoken to directly,” and “often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).” You can see that each of these “criteria” is a matter of adult judgment. Concepts like “listening well” or “holding attention,” not to mention the qualifier “often,” are not things that can be measured objectively. They are all based on the opinion of the observer.
You may have heard that “ADHD” is a “neurobiological disorder” of the brain, or that brain scans can distinguish “ADHD” children from “normal” children. There are no such tests given when a child is brought to a doctor for an assessment. The “diagnosis” is made from the kind of subjective behavioral criteria described above. This means that whether a child “has ADHD” or does not is essentially a matter of opinion. And everyone is entitled to an opinion, including you and your child!
You may also have heard that stimulants affect kids with ADHD differently than they do other kids, calming them down (this is known as the “paradoxical effect”). So you can allegedly tell if the child “has ADHD” by trying him on stimulants. This belief was disproven by Judith Rapoport and colleagues, researchers from the National Institutes of Health, in the late 1970s. Children respond very similarly to stimulants, whether diagnosed with “ADHD” or not, so their response to stimulants is not a method of “diagnosis.”
Another unfounded notion is that “untreated ADHD leads to bad outcomes” such as school failure, delinquency, drug abuse, teen pregnancy, low self-esteem, or other issues school staff may mention. What most won’t say (probably because they don’t know the facts) is that stimulant drugs have not been shown to improve any of these outcomes despite many years’ worth of studies. Some actually show a worsening of some outcomes, as you can read here, here, and here.
So don’t let school staff intimidate you into thinking you’re risking your child’s long-term welfare by refusing to give him stimulants. “Treated” and “untreated” children with ADHD diagnoses do about the same in the long term academically, socially, and emotionally. The only consistent advantage that stimulant drugs have been shown to offer is that they make it easier for the child to maintain decorum in a standard classroom, with less disruption in the short term. We can easily see why teachers and school staff—and even other parents and kids—might want this result, but the benefits to a child are generally temporary and the risks they assume are very real.
Active kids often have a hard time managing in a regular classroom, where they are expected to sit at desks and follow directions from the teacher, and they are often bored. However, studies as far back as the 1970s have shown that “ADHD” children do so much better in an “open classroom” that professionals are unable to distinguish them from “normal” children, though the professionals very easily find the “ADHD” children in a standard classroom setting. (In an open classroom the kids are freer to move around and make more decisions about how they spend their time.) This is what my wife and I did with our “ADHD” type kids—we put them into schools with open classrooms and even helped create a charter school that would better meet their needs. Both graduated from high school with honors, having never taken a milligram of any kind of stimulant.
So one option is to find a classroom or school whose structure better meets the needs of your child. There is nothing inherently wrong with being active and wanting to move around—in fact, studies have also shown that “ADHD” kids learn better when they are allowed to move their bodies more freely. So why not find an environment that allows these kids to learn the way they learn best?
If you are unable to find a more appropriate classroom, remember that there are lots of things that a teacher, a parent, and the child him/herself can do to make it easier to survive in a standard classroom without involving drugs. The main thing that distinguishes the “ADHD” children from the “normal” ones is that they need/want more stimulation. So why not provide it for them?
- Allow the child to move around. Sitting balls, fidget spinners, working standing up, or anything that provides an opportunity for movement in a less disruptive manner is something to try.
- Give the child a music player with headphones: Many “ADHD” kids work better when they have some kind of auditory stimulation. This is one reason that they have no problem concentrating on video games—the constant visual and auditory stimulation keeps them engaged.
- Make learning into a game. Challenging your “ADHD” kids to concentrate for a certain length of time or to complete a certain number of problems in a certain period can take a boring activity and make it fun and engaging.
- Allow the child to finish tasks on his own schedule, rather than forcing a change of activities at random times. This is one of the reasons “open classrooms” work better for these kids—they don’t like to be interrupted and redirected for apparently random purposes. They are often able to focus on subjects for a long period, but only on those subjects in which they are interested. Once they’re hooked, they don’t want you to stop them!
- Minimize the amount of busywork, especially if the child is smart and learns quickly. There is no purpose in insisting on repetitive work production in a subject the child has already understood and mastered, and many avoidable power struggles in school are over this very issue. Presenting him with new challenges can both make him feel special and provide that extra stimulation and challenge he loves.
- Create a list of alternative activities with the child that he is allowed to do when done with his schoolwork or when he doesn’t want to participate in a particular activity. As long as the child does one of the activities on the list, there are no negative consequences. This keeps the child stimulated and out of other kids’ hair, and also gives a sense of autonomy that is very important to many of these students. We did this with our youngest and found that if he was allowed to choose alternative activities in school, he often decided to rejoin the group of his own volition after a short while. He could enjoy these group activities, but simply hated to be bossed around. Problem solved!
- Try out new ideas. Be creative! We used to bet our kids that they could not do things that we knew they could but which they would not want to try. They always found this challenge extremely amusing, even when they figured out that we were messing around with them. It made compliance fun!
All of these interventions can be requested as “accommodations” if your child has an Individualized Education Program (IEP) or a 504 (special education) plan.
Many more ideas are available online and in books. One excellent resource is the work of Thom Hartmann, who sees ADHD as simply a human personality variation that had a lot of value back in our hunter/gatherer days. He has a list of 101 non-drug strategies that is well worth exploring:
Researcher Dr. Sydney Zentall also offers some great suggestions for supporting “ADHD” kids in both school and home settings.
Unfortunately, some teachers or schools are simply not equipped to handle “ADHD” kids and are not willing to try new things. If you can’t find a school or classroom that fits your child’s needs, you might consider homeschooling. That way, you can adapt your structure and curriculum to your child’s needs. We did this with our oldest from second through fifth grade and had no regrets. I know not all parents can arrange to homeschool, but it is one way of avoiding conflict with the schools.
When You Visit the Doctor
It is also important to have a doctor check for other physiological issues that can contribute to your child’s concentration problems. These problems may include low iron, thyroid issues, sleep apnea, allergies, and low blood sugar, among others. Also, before considering medical intervention, be sure to talk with your son about his experiences at school, including how he feels in class, how the teacher treats him, how other kids treat him, what he likes about it, and what he wishes were different. This may help you decide if the problem is your child’s or stems from a poorly-managed school environment or a poor fit for his needs.
If you do decide to try stimulants, make sure goals for “treatment” are very clear at the beginning, and that hard data are collected and frequently reviewed to make sure that these goals are being met. Ensuring that the child is less annoying to the teachers is not a legitimate outcome! You want the school or teacher to set goals such as “Finishes homework X number of days a week,” “Stays in classroom all day X days in a row,” and “Does not get in fights with peers for X days a week.”
Best of all, have your child create the goals he thinks he needs to work on! Remember that the behavior changes from the drugs are all short-term benefits that will last only as long as the drugs are in the child’s system, and generally do not improve long-term outcomes. So even if the drugs “work,” make sure you, your child, and his teachers are also finding ways to help him deal with dull or demanding environments so that he can gain the long-term skills necessary to survive in life.
Any drug benefits must also be weighed against the negative side effects of the stimulants, which are quite common. They include loss of appetite, sleep problems, loss of emotional expression, and increased aggression, among many others. In a small but not rare number of cases (over 6%), hallucinations or other psychotic symptoms may occur. Check the product information sheet included with the prescription to learn the full range of possible side effects and watch out for them. It’s also important to realize that the long-term adverse effects of stimulant use in childhood on development have never been studied in any depth and are therefore unknown.
So if you see any indication that the stimulants are not helping meet the intended goals, or notice that the adverse effects are severe enough to make whatever benefits you see seem less important, by all means, insist on stopping the drugs in consultation with a competent medical professional. (Suddenly stopping psychoactive drugs can cause adverse effects and tapering is often necessary.)
As a parent, whether or not to consider stimulants for your son is entirely your decision. Decisions about how to support children in school are very personal and highly dependent on the individuals and families involved. Teachers are simply not in a position to understand the values and priorities of your family nor the specific needs of your child. Your son is counting on you to advocate for him in these difficult situations, and you must be willing to stand up and insist on what is right for him even if the school doesn’t like it. He has to be there many hours a week and has little to no power to alter his environment. He’s counting on you to speak up for him!
Steve McCrea, MS, is a mental health professional, advocate and author who has worked for over 30 years in social services, including over 10 years as a mental health professional. He currently works as an advocate for foster children. He is a member of Portland Rethinking Psychiatry, an educational and advocacy group inspired by the works of Robert Whitaker.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.