Published Online: February 26, 2013
Published in Print: February 27, 2013, as Why ADHD Medication Is Not Reform

Commentary

ADHD Medication Can Help Kids, But It Can't Fix Schools

I think we can all agree that reforming schools through medicating students would be misguided, even ridiculous.

Yet The New York Times reported last fall that some physicians, particularly in low-income communities, are prescribing stimulants to students as a way to compensate for their inadequate schools. The children cited in the article didn't suffer from attention deficit hyperactivity disorder, but they weren't receiving the educational services they needed. Some physicians told the Times that they used medication to level the playing field for their young patients. This practice produces a new equation for education reform: Boredom + distraction = medicine.

At times, medication is necessary for students with a diagnosis of ADHD, and it can be daunting for poor families to access good diagnostic assessment and therapy. But the use of stimulants to improve poor academic performance or enhance cognitive skills is a travesty that can lead to unintended consequences.

Education reform does not come from introducing Ritalin into the cafeteria lunches of poor schools. Real reform comes through productive interaction between teachers and students in the classroom.

As a child psychiatrist who consults with urban schools, I believe mental-health clinicians must provide every student, rich or poor, with a thorough diagnosis that determines if he or she has a learning disorder, anxiety, sleep deprivation, or another condition that fuels difficulty in school. But those same mental-health practitioners then need to help teachers find strategies to address the underlying problem effectively.

Many teachers do not get the support they need on how to work with children struggling with mental-health problems. Too often, teachers enter the classroom ill-equipped to respond to students' challenging behaviors: their refusal to do work, defiance of teacher authority, persistent arguing, or, in the words of one principal I know, their ability to go from "zero to 100 in a split second."

Faced with challenging students, teachers often feel exhausted or incompetent. There is a 20 percent annual turnover rate among urban teachers, and 46 percent of new teachers leave the profession within five years.

Too many educators receive minimal training in how to develop interventions that reduce behavioral incidents and increase access to the curriculum—and yet training in basic preventive techniques can provide the key to student learning. This allows teachers to convey the message that their students are promising, safe, and appreciated. These preventive approaches can have a huge impact on students and help them fit into the school environment.

"Too often, teachers enter the classroom ill-equipped to respond to students' challenging behaviors."

So what should teachers do when students have trouble regulating their emotions, become inflexible, and subsequently explode? The first step in working with challenging students is to understand some key concepts. Teachers need to learn to see all behavior as a form of communication. This fundamental principle helps when teachers are frustrated or confused by how students are acting. Even though students' behavior can look bizarre or disruptive, their actions are purposeful attempts to solve a problem. Rather than responding with bewilderment or assuming that the child is being manipulative, it helps to ask: What is this student communicating? This allows the teacher to begin to decipher what the student is trying to convey and to identify the underlying cause of the outburst.

Behavior happens for a reason, and by determining the intent or the function of the behavior, teachers can better decide how to intervene.

Unfortunately, as many teachers know, negative attention, such as lecturing or redirecting a child, can reinforce the student's attention-seeking behavior. By looking for patterns in students' behaviors, teachers can avoid that negative reinforcement and instead reduce environmental triggers for bad behavior (such as transitions, unstructured times, lunch, and recess), as well as explicitly teach replacement behaviors and improve underdeveloped skills.

Many students with challenging behavior lack the skill of self-regulation, and teachers may need to help students identify their feelings and then encourage them to practice self-calming strategies to avoid a meltdown. If students find a way to get their needs met and improve skills such as self-regulation and flexible thinking, they can develop the necessary confidence to make effective progress.

Admittedly, teachers are extremely busy and may need to be persuaded to step back and look at a child's meltdowns as an opportunity for growth. However, investing time upfront often ends up saving a teacher's time by preventing a lesson plan from being derailed by one student's actions. It takes a lot of energy to settle a class after a child has thrown something or started to swear. For the teacher who thinks that it's not his or her job to work with such a student, and that the student just needs to go somewhere else, keep in mind that inevitably the teacher will face another child with similar challenges.

How does one put all this into practice? Let's consider Fred, a 4th grader who has already lived in two foster homes. Every day at school, he has three explosive incidents that seem to come out of the blue, and he has been sent home twice. By looking for patterns in Fred's behavior, the teacher identifies writing and social demands as triggers. In the past, she focused solely on the meltdowns, but after gathering information, she focuses on what happens before Fred's meltdowns.

She realizes that Fred struggles with behavior after lunch and recess and when writing is required in class. This helps inform her interventions. She sees that her student was stuck in a cycle in which he had discovered that demanding behavior would get him what he wanted. As a result, she understands that she needs to teach Fred to take a deep breath in a moment of panic and to learn to say "I'm frustrated," instead of screaming. The teacher emphasizes positive self-talk, and the school counselor helps with coaching in social skills. The teacher provides a "comfort box" for Fred, which includes theraputty (a kind of hand-exercise putty), a "power card" with a motivational character, and a picture of his family, among other soothing items.

The teacher and the student break down the writing tasks to help with his anxiety, and they preview all writing assignments with pictures to help him get started. Within three weeks, Fred does remarkably well with this plan. He stops his explosive behaviors and is able to complete many tasks. He uses self-calming strategies and is better able to get along with his peers.

When the teacher consistently applies such simple interventions to address underdeveloped skills, she curbs the student's disruptive behavior.

It takes experience and a nuanced eye to determine whether a child is suffering from ADHD, boredom, or something else entirely. Forget the shortcuts that may seem convenient or a quick fix. When we medicate our children this way, we are cheating the kids and ourselves. The price is too high for our children to pay. Many students don't need prescriptions. They simply need teachers trained in preventive strategies, which are key to providing them with a chance to learn and the skills they need to persevere.

Vol. 32, Issue 22, Pages 23,25

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