Boyhood and Poverty Are Not Medical Conditions
By Kate Lapham
In the United States, boys are more likely to be diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) than girls, and children covered by Medicaid insurance, an indicator of poverty, are one-third more likely to be diagnosed. This is according to new research from the Centers for Disease Control (CDC) on children aged 4 through 17 years old in the United States.
There is significant variation in diagnosis rates by state, which is unusual for other types of learning difficulty, and opinion is divided on how diagnosis rates differ according to race. Some researchers believe that children from minority groups in urban areas, particularly African American children, are disproportionately diagnosed with ADHD. Although rates of diagnosis have increased as a whole, another study in the peer-reviewed journal JAMA Pediatrics finds the rates of diagnosis increasing more rapidly for white children in high-income families, but concedes there has been a significant increase in the diagnoses among African American children as well.
The interaction of socio-economic status, race, and ADHD diagnosis are complex. Qualitative research indicates that some parents have sought ADHD diagnoses to provide their children with the edge of extra time and drug therapies that enhance concentration. There is also a thriving black market in ADHD drugs as study aids on college campuses. On the other hand, there is evidence that children from minority groups are more likely to be placed in special education or separate classrooms with a non-academic track. Thus, a diagnosis of ADHD can ease the path to higher education and subsequent opportunities for some, while possibly limiting it for others.
Regardless of race or class, the drugs used to treat ADHD are stimulants like Adderall and Ritalin. These drugs can help children who suffer from ADHD. However, the guidelines for diagnosis are loose and set to become looser in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders to be released in May. While ADHD is a real condition, there is substantial debate in the medical community about what constitutes a level of the disorder requiring medication. The drugs used to treat ADHD are powerful and relatively new. We do not know the consequences in later life for children and teens—whose brains are still developing—of using these drugs now. With such loose guidelines, unsettled professional debates about ADHD and appropriate therapies, and wide availability of drugs, there is ample room for parents and teachers to seek a diagnosis and prescription, when flexibility and additional support in the classroom might also work as solutions.
The collision of health and education policy leads to the results revealed in the CDC study outlined above. To understand how we have arrived at such a huge increase in ADHD diagnosis, we must look at both health and education policy. Of course, parents will have an understandable desire to provide the best opportunities for their children. At the same time, the accountability movement has pushed schools to increasingly focus on the reading and math needed for the standardized tests. A rigid focus on test readiness, and the subsequently narrow definition of success in education, puts children who have difficulty sitting still for long, test-driven lessons at a disadvantage.
Although easy to measure, this type of schooling comes at the high cost of failing to support the whole child with educational experiences that encourage cognitive, social, and personal development. This is particularly true in school districts without the budgetary resources to support both test preparation, and a wider, richer range of educational experiences. These are also the types of educational experiences that support the values of diversity, citizenship, and open society.
Provision by the state of early childhood programs, and individualized support for children who have difficulty in school, are expensive. Although both have been proven to provide good results, budgetary incentives in the current economic environment in school districts work against them. Economists like James Heckman have proven that funds invested in high-quality preschool programs yield significant savings in social services later on. However, the costs and savings of these programs are often realized at different levels of government, which can make the initial funding difficult to allocate.
Finally, ADHD drugs are widely available, and their cost is borne by insurance companies and parents, rather than the school system. They are marketed to both doctors and the general public, and there is a strong incentive for pharmaceutical companies to sell these drugs. Like any company in the private sector, they make profits for shareholders by producing a competitive product. This can encourage research leading to advances in science and therapies for children who need them. However, profit motive should not be confused with a public policy response in either health or education, just as purchasing power should not be confused with citizenship.
The collision of these health and education policy trends, with private sector interests also in the mix, risks leading to a fragmentation of services, perverse budgetary incentives, and poorer outcomes for society as whole. This is particularly the case for those most marginalized and least able to navigate this complexity.
Right now, we run the risk—through our health and education systems—of turning boyhood and poverty into medical conditions. This will carry real and damaging implications for education in the United States. The incentives of private companies, along with rigidly defined education goals driven by a free-market agenda, may be conspiring to do a grave disservice to our children through the over-diagnosis and over-medication of ADHD. When medication and test preparation are in danger of replacing rich, supportive educational experiences, we deny children their right to education and risk profoundly damaging our societies now, and in the future.
Until November 2021, Kate Lapham was the deputy director of the Open Society Education Support Program.