When I graduated from college in 1974, I felt well-prepared to work as a speech and language pathologist in the public schools. I knew how to use an articulation test to screen for speech delays and pronunciation problems. Using a variety of standardized and informal assessments, as well as teacher input, I could determine areas where a child was struggling with language comprehension and expression. I easily performed routine hearing screenings to determine whether a child needed a full audiological workup. But what I wasn’t prepared for was making recommendations to parents for children who were labeled as “hyperactive.”
During my second year of working in the schools, one of my duties was working on a screening committee. The screening committee in my school consisted of the assistant principal, the school psychologist, the reading specialist, the classroom teacher making the referral, and the speech pathologist (me). Children were referred to the committee for a variety of concerns—struggles with reading or math; speech, language, or hearing problems; and “hyperactivity,” which was later renamed as Attention Deficit Hyperactivity Disorder (ADHD).
Three aspects of the screening committee’s discussions regarding the children, almost always boys, that either teachers or parents considered to be hyperactive stand out for me. When we surveyed the child’s records, we almost always discovered he had what we euphemistically called a “late birthday” because he was born near the end of the year. That meant that he was usually one of the youngest children in the class. Additionally, when we checked into the child’s home life, we often discovered that his parents had recently divorced or there’d been a death in the family. And lastly, there was always someone on the committee, often the assistant principal or the school psychologist, who recommended that the parent seek a medication consultation for the child.
At that time, Ritalin seemed to be the most common drug in use, and often the parents would comply. When the committee followed up on the child’s progress in two or three months, the teacher typically reported that the child had improved because he stayed in his seat, followed directions, and did his homework. Complaints about the medication commonly came from the parents because the child had trouble sleeping or lost his appetite. I also remember hearing things like, “He seems to be very irritable when the meds wear off,” or “He’s into everything on the weekends.”
When I asked the school psychologist about the effects of a stimulant like Ritalin, all he told me was that the drug worked differently in someone with hyperactivity, and that it helped them to pay attention in school. And that as long as the parents gave the child a break from medication on the weekends and during summer vacation, problems with appetite, growth, and sleep should resolve normally. Since my introductory special-education classes in college barely skimmed the topic of medication, I figured that was all I needed to know.
My Son Gets Labeled
I stopped working as a speech pathologist and special education teacher in the 1980s after my own children were born. Both of them appeared to hit all their developmental milestones on cue and were beginning to read by the time they entered kindergarten. They loved creating with art materials, building forts in the woods, and riding their bikes. I never imagined I’d one day be called in for a conference to discuss learning or behavior problems.
Connor settled into the kindergarten’s routine but told me that sometimes he didn’t want to do the assigned classroom activities, so the kindergarten teacher kept him in from recess. Still, he did well overall and began first grade enthusiastically. He had lots of friends, did all of his work with ease, and genuinely seemed to enjoy school. So I was shocked when his teacher told me she was unhappy with his progress. When I arrived for our conference, she walked me over to his desk, which was stuffed with unfinished worksheets.
“I think you should have Connor checked for Attention Deficit Hyperactivity Disorder (ADHD),” she told me.
“What? Connor can play with Legos for hours by himself, he follows directions the first time I ask him to do something, and I don’t have any serious discipline problems at home. I don’t understand.”
“He has piles of unfinished work, and that’s often a sign of the disorder.”
My husband and I were both astounded by what the teacher was telling us. We were moving at the end of the summer, meaning Connor would have a fresh start in a new school, so we decided to ride things out and see what the new teacher recommended.
As we’d expected, Connor adjusted to his new school with ease, made several friends, and seemed to be doing well in class. But one day, he and a friend were playing around in the classroom and Connor stuck out his foot and tripped the boy. His teacher asked me to come to school for a conference. Connor was there waiting in the office, and after he told me what had happened, he said, “I apologized to Mark, Mom. I didn’t mean to hurt him.” From what the teacher said, Mark appeared to be fine, but she wanted the hijinks to stop. I assured her that she’d have no more issues with Connor. The principal caught me on the way out of the building and issued a stern demand: “Get your kid under control. Either you medicate that boy, or I will.”
I’d never thought Connor needed any kind of medication to control his behavior. He was basically a sweet boy, but like all kids, he could sometimes be impulsive. Did he really need medication for that? I spoke with his pediatrician, who gave me two checklists—one for me and one for his teacher. The teacher had more areas of concern than I did, and so the doctor recommended starting Connor on Ritalin to help with his impulse control. I trusted the doctor, so we told Connor he’d be taking some medicine so he could pay attention better in school. After a few days on it, as I was tucking him in for the night, he asked me, “Mommy, will that pill make me better?”
His question unsettled me, and I decided to find a child psychologist who could offer more guidance. He laughed off the diagnostic survey of symptoms, saying, “You certainly need more than two people offering their opinions on a checklist before you start giving your child Ritalin.” He met with Connor several times over the next two months, as well as with me and my husband, and assessed Connor’s school achievement. His conclusion? “Besides being a little bored in school, Connor’s a well-behaved, normal kid. I’d recommend he be given a few enrichment activities to do when he completes his regular work. And you can stop giving him Ritalin.”
Connor’s difficulties with school continued, however. Looking back on those years, I realize now that because he wasn’t challenged, he saw no point in doing certain assignments. He was learning what he needed in order to pass, and the rest he just ignored. He graduated from high school without distinction and then waited a couple of years before starting college. When he got his first-semester grades, he had earned As in all of his classes.
“Connor, your grades are wonderful. What’s different between now and your grades in high school?”
“Simple, Mom. College counts.” It would take me quite a while to unpack that lesson. Connor told me he cared about his college work because he was taking classes he was interested in and he knew that if he did well, his success might land him some good internship or job opportunities.
My Return to the Classroom
After a 20-year hiatus, I returned to working as a special education teacher in 2000. My credentials were in high demand, so I had no trouble getting a job. I taught at a few high schools, both public and private, as well as in a psychiatric hospital’s high school program. The schools looked much the same as when I’d left in the 1980s—a teacher’s desk at the front of the room, one or two blackboards, and the students’ desks lined up neatly in rows. Some teachers even had tape on the floor to indicate the desks’ placement.
With my dual certifications in English and reading, I was often paired with a classroom English teacher in what’s called a co-teaching model. Usually, this involved supporting the special-education students with Individual Education Plans (IEPs). I helped them to write their papers, organize their notes, and complete assigned projects.
But while the classroom layout and many of the methods of teaching hadn’t changed over the years, I had. Especially in the way I viewed the students (again, usually boys) labeled as having ADHD. Because of my experiences with Connor acting up or not completing his work due to boredom, I now saw my students in a softer, less judgmental light. Connor had helped me to realize that I’d been trying to make him fit into a traditional model of school achievement; thankfully, his success helped me to value alternative learning paths.
Instead of seeing kids who wanted to disrupt the class, I saw kids who were either bored or in over their heads. Behaviors like rolling a pencil back and forth on the desk and then dropping it and tipping back in the seat to retrieve it signaled to me that the student either needed an alternate activity or was embarrassed to ask for help. The student who continually called out the answers or made loud jokes in the middle of the lesson was often frustrated because something in the lesson wasn’t clear. And when a student rocked a lot in his chair or walked back and forth to the trashcan or pencil sharpener repeatedly, it usually meant he needed a way to burn off energy–so I’d invite him to do a couple of laps around the building with me. We had a chance to talk about the class and get some movement in. And while the kids often groaned and complained when I said, “Let’s take a walk,” we usually wound up having a good conversation. Because of the one-to-one time, the student felt special instead of uninterested or confused.
As I got to know them better, I found that some of my students who had a hard time paying attention or completing their work were struggling at home as well. One boy was living with his aunt and uncle because his parents’ alcohol use had rendered them unable to parent him. He was a bright and creative person who loved to write and played drums. Another boy’s family had been unhoused until they moved in with his uncle. One day he told me that his family of four was now sharing a three-bedroom townhouse with his uncle’s family of seven. No wonder he put his head down on the desk in the afternoon and lagged behind in his reading skills. Both young men had plenty of reasons to be distracted and wander off task.
One of the biggest lessons I’d learned from parenting that I was able to use in my classroom was the need to teach a child some kind of self-management skills—what to do when they felt frustrated or angry, how to manage anxious feelings, and how to break down a large task into smaller chunks. Since we always had Playdoh in the house, I suggested that the kids pound on a clump of it when they could feel themselves getting angry. My daughter often got very nervous before she had to take a test, so I taught her how to sit quietly, take deep breaths, and repeat a positive message to herself. And when one of the kids had a long-term project like reading a book and making a poster presentation, I worked with them to make a list of what they needed to do and then schedule time for the different tasks in their homework planners.
These parenting tools and my experience of raising a son who was bright and creative but didn’t fit the mold helped me to approach my students more compassionately and creatively. Even when one boy, a ninth-grader I’ll call Tommy, called forth all of my patience. Tommy was taking some kind of stimulant medication, but by the end of the day, he seemed about done. Tommy called out all the time, made jokes, and randomly got up and walked to the back of the room to sharpen his pencil—all the while managing to avoid the classwork for the day.
I was assigned to be his case manager, which meant I coordinated with all of Tommy’s teachers on helping him, kept track of his progress, and communicated with his mother, who I’ll call Mrs. Miller, on a regular basis. One day, Mrs. Miller called me and was clearly out of patience. After she rattled off all the ways Tommy was a problem at home and in school, she said, “I’m going to up his medication. He’s just out of control.”
I still didn’t know much about stimulant medication, but I knew that more meds weren’t the answer to Tommy’s learning and behavior issues.
“Mrs. Miller, I can hear that you’re frustrated now, but there are lots of other options for you and Tommy. Why don’t you come in for a conference and we can work out a plan?”
Mrs. Miller came in later that week, and I’d had time to put some ideas together. I began our conference by telling her some of Tommy’s strengths as a way to help her see her son with fresh eyes. “He’s got a great sense of humor, and he’s always kind to the other kids in the class.”
That bit of praise for her son went a long way to smoothing the path for my suggestions.
“Mrs. Miller, Tommy’s a creative kid, and that means he’s filled with all kinds of ideas and possibilities. That’s his gift, but it’s also a trait he needs to learn to manage. I’d like to help him learn some self-management techniques because whether he continues with medication or not, he needs to learn how to successfully juggle his responsibilities.”
Together, Tommy and I agreed on a four- or five-item plan that he kept in a folder on his desk. A few things he needed to work on were putting classroom handouts in the “Notes” section of his binder, working on a task for at least ten minutes before getting up to sharpen a pencil, and using a graphic organizer to help him structure paragraphs for short essays. If he needed a reminder to refocus, I’d tap his chair instead of calling out his name. We talked about how he was doing almost every day, and I think he was ultimately successful because he’d been involved in deciding what he needed to do. Because he had agency in the process, he felt ownership. Any tangible “rewards” his mother gave him were secondary to his growing confidence and stronger executive function. Tommy’s success helped his mother to feel better about his behavior and school achievement. But the real reward was helping Tommy see himself differently because he was learning how to channel his attention and energy in more productive ways.
Finding a Better Way Forward
During all of my years in college, graduate school, and working as a special educator, I never had any in-depth classes or workshops that explored the positive and negative effects of using stimulant drugs to improve attention and control behavior. I’d also never looked into them myself –I probably read the package insert when Connor briefly took it, but he never had problems, so my curiosity stopped there. And yet, among all of the teachers and psychologists I worked with, stimulant use was widely, almost casually, accepted and rarely questioned. It wasn’t until I’d left the public schools and began teaching in the Professional Writing Program at the University of Maryland that my education around the use of stimulants began when I read The Anatomy of an Epidemic by MIA founder Robert Whitaker.
The book provided several pieces of information I wished I’d known when I was teaching and when confronted with an ADHD diagnosis for my son. For example, it would have been important to understand that over time, stimulants often affect a child’s self-esteem because they believe that there’s something inherently wrong with them that needs to be fixed with a pill. Meanwhile, there’s no evidence that using stimulants results in long-term improvements in a child’s behavior. And while stimulants reduce what many teachers might call short-term “annoying behaviors,” like finger tapping, off-task behavior, and classroom disturbance, there’s no evidence that the drugs improve academic achievement in the long run. Herbert Rie, one of the researchers Whitaker cites, found that Ritalin failed to improve “students’ vocabulary, reading, spelling, or math, and hindered their ability to solve problems.”
But for me, the most disturbing information was in a chart in which Whitaker compares the side effects of stimulant drugs to the symptoms of bipolar disorder. (Editor’s note: You can view that chart here.) Alarm bells went off in my head when he explained what the numbers of kids diagnosed with either disorder meant in real-life terms: “If a society prescribes stimulants to 3.5 million children and adolescents…it should expect that the practice will create 400,000 bipolar youth.” And a diagnosis of bipolar disorder most likely will lead to a lifetime of psychiatric drug use.
Even with all of these alarming findings on the harmful effects of stimulant drugs on children, many doctors continue to routinely prescribe them, and the general public views them as basically harmless. I believe we need to address the casual use of these drugs by, for example, providing more in-service training for teachers on alternative behavior management. Teachers also need a much deeper understanding of the research on the effects of stimulants so that they can understand the pitfalls of the all-too-available chemical cure. Teacher preparation programs should include a unit on the harms of using stimulant drugs. And most importantly, parents deserve fully informed consent when presented with the option to medicate their child. I believe that if more teachers and parents realized that the drug companies’ offer of a magic pill is really more of a poison apple, they’d look for a better solution.
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.
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