They get expelled from preschools five times more than girls and are diagnosed with learning disorders four times as often. In her new book, "The Trouble With Boys," journalist Peg Tyre explains why schools are failing our sons and in this excerpt, she takes a hard look at the rising rates of ADHD among boys.
Chapter eight
Pay attention: Your son, his teacher and ADHDAs six-year-old Kai Farquhar tells it, he ran into a bit of trouble in first grade. Mostly, he wants you to know, he likes school, “especially P.E., library, music, and art.” He likes to read, too — and his parents will proudly tell you that he devours books at a fourth-grade level. So what’s the trouble?
“I can’t complete a journal entry,” Kai confesses, his blue eyes and thick eyelashes growing moist. Why not? He thinks for a minute, then looks down at his hand, which often starts to ache when he writes for a long time. “Oh, man!” he says, flexing his fingers. “I just get sick of doing it!” What happened when he didn’t finish his journal? The teacher, he says tremulously, “would give me a look.” A look? “She’d be doing her papers and I’d be not doing my work and she’d give me a look.” He shakes his mop of brown hair as if he’s still amazed that he survived it.
Kai’s parents are a little frightened of the teacher, too, but for other reasons. For the last eight months, they’ve been caught in a vise: They believe their son is a bright normal boy, but the teacher and the school think Kai has an attention deficit and should be on Ritalin.
Kai’s problems, such as they are, are a relatively recent development.
Kindergarten and the first half of first grade were a breeze. Back then, Kai’s teacher had nothing but wonderful things to say about him. Shortly after Christmas break, though, Kelley and Tim Farquhar, who live in a suburb outside Kansas City, noticed that Kai was struggling to get his math and writing homework done. “Writing has always been a problem since he can’t really control his pencil yet,” says Kelley, who works in a bank. She gives a little laugh. “He’s got the handwriting of a serial killer.” He’s also bored to death with the drill-it-till-you-kill-it approach to math homework. “The same problems, with the same numbers over and over again,” says Kelley. “We’ve had lots of tears — both his and mine.”
When Tim, a stay-at-home dad, picked Kai up from school, the teacher began signaling that there was trouble. “He’s not getting his work done,” Tim kept hearing. “The teacher said, ‘He’s daydreaming. He’s out in left field,’ and ‘even when I stand on top of him, he’s not paying attention.’ ” Tim started to worry.
Soon, the teacher started sending Kelley and Tim notices that Kai had a “red day,” meaning he hadn’t finished his work in the allotted time, he was talking to other kids, or he was acting silly. “None of those infractions seemed all that serious to me,” says Kelley. Tim, though, decided to sit in on class one afternoon and try to get a sense of the problem. “I couldn’t help but notice that all of the kids who were having ‘red days’ were boys,” he says. Around that time, the teacher and the school nurse began a steady patter of “suggestions” urging Kelley and Tim to “get Kai tested.” Kai is Kelley’s only child, but she knew what that meant. She had heard plenty of other parents talk about taking their children for an evaluation, getting a diagnosis of ADHD, and then trying various medications.
“I wondered if it was really necessary,” says Kelley. She stalled, but the “suggestions” grew more pointed. It’s against the law for school personnel to pressure parents into giving a child attention-enhancing drugs, but Kai’s school got the message across.
“The teacher would say, ‘Kai had a bad day today. Have you taken him to the doctor? You know, [Kai’s classmate] is on Ritalin and he’s been having mostly good days,’ ” says Tim, his voice filled with anguish and self- doubt. “Growing up, you’re taught that a teacher is an authority figure. And you figure she probably sees lots of kids. They act like you just don’t know what they know because you’re an inexperienced parent. They act like they know what’s good for your kid more than you do.”
Kelley and Tim resisted.
Finally, in the spring, they broke down. They asked the teacher for a note detailing Kai’s problems. She listed Kai’s frequent daydreaming and failing to complete his journal. Then Kelley, Tim, and Kai went to their local pediatrician. The doctor spent 10 minutes examining Kai, read the teacher’s note, and handed Kelley and Tim pamphlets for different ADHD medications. “Sounds like ADHD to me,” she told Kelley and Tim. “Take a look at these and see which one you want to put him on.”
The couple looked around the examining room. Logos for popular attention deficit drugs were emblazoned on the notepads, the pens, the posters, the pencil holder jars, the Kleenex box, the doctor’s own stethoscope, and the little hammer she used to test Kai’s reflexes. They grabbed up their son and backed out of the office.
That afternoon, Kelley called a renowned hospital in Kansas City and put Kai on the waiting list to get a second opinion. He’ll be evaluated — in eight months. Tim is dreading it already: “I feel like we’re all getting sucked into something we don’t think is right for Kai.” It seems to him that the school doesn’t have enough tolerance for typical boy behavior. “But at the same time you worry because maybe there is really something wrong with my kid.”
The “epidemic” of ADHD
Few discussion topics around the sandbox can spark a controversy more quickly than the diagnosis and treatment of attention-deficit/ hyperactivity disorder. The National Institutes of Health describe ADHD as a lifelong mental disorder that affects approximately 3 to 5 percent of the population. Although the disorder was largely unheard of before the 1950s, attention deficit medication in the United States is now a $2.7 billion industry. Plenty of people, including some well-known research scientists, think that the widespread acceptance of ADHD marks a step forward in our understanding of human behavior. Plenty of other people, including some well- known research scientists, believe that the diagnosis and treatment of ADHD in this country is an example of junk science run amok. But there is one point about which both sides agree: There’s no medical test for ADHD. The identification of the disorder results from a series of highly subjective judgments.
Drug companies and Big Pharma–sponsored ADHD support groups insist the squishy diagnostic process means that ADHD is underdiagnosed — that many people have the disorder but never get sensitive medical care and the proper treatment. But when you look at the national data, one subgroup of the American public is getting identified and treated for ADHD at a truly astonishing rate: school-age boys.
Before you sit down to write me a nasty letter describing how ADHD is real and how ADHD meds helped your son, let me say this: I’m not pulling a Tom Cruise here. I’ve met very few responsible thinkers on this topic who believe that ADHD doesn’t exist at all. For some people — including some school-age boys — the arsenal of ADHD medications is nothing short of a godsend. That said, let’s take a harder look at who is being medicated for this disorder, who is doing the diagnosing, and why.
According to the Centers for Disease Control, in 2003, 14 percent of boys across the nation were identified as having ADHD by they time they reached their sixteenth birthday. And the percentage is continuing to grow. Between 2000 and 2005, the number of boys from birth to age nineteen who were being prescribed ADHD medication grew 48 percent. That such large numbers of boys are being diagnosed with a central nervous system disorder suggests two things: Either we are witnessing the largest pandemic in our country since influenza struck in the United States in 1918, or school-age boys are being overidentified and overdiagnosed.
Why are boys in the crosshairs? Maybe it’s all about biology. We know that for complex biological reasons, boys are more vulnerable to genetic anomalies than girls. It’s possible, then, that they also might be more susceptible to as-yet-unknown environmental or chemical causes of the disorder. But other factors — including the higher academic expectations, zero- tolerance policies, and shrinking of recess that we’ve been talking about — may be making boys’ behavior seem less normal and more pathological.
According to researchers who study dosage patterns, affluent white boys (who attend the schools where expectations for academic achievement are most intense) and poor black boys (who attend underfunded, overcrowded schools with a high proportion of inexperienced teachers) are most likely to be identified as having attention problems and given medication. In two southeastern Virginia school districts — one poor and one affluent — a researcher at Eastern Virginia Medical School in Norfolk found that 20 percent of white elementary school boys, one in five, line up at nurses’ offices at lunchtime to take stimulants in order to get through the day. In a follow-up and as-yet-unpublished study, the researchers culled information from nurses and parents at three middle schools in the same area and found that an astonishing 38 percent of white boys were diagnosed with ADHD and 100 percent of them were taking medication for it. For boys, getting a neuropsychological workup or “getting tested” and trying out attention-enhancing medication is becoming a perverse right of passage.
From daydreaming to Ritalin
Who does the diagnosing? What training do they have to determine which attention spans need enhancing and which do not? Let’s take a step back and see how it works.
In order for a child to be identified as having ADHD, the child has to have six of the following nine symptoms:
- Fails to give close attention to details or makes careless mistakes.
- Has difficulty sustaining attention.
- Does not appear to listen.
- Struggles to follow through on instructions.
- Has difficulty with organization.
- Avoids or dislikes tasks requiring sustained mental effort.
- Loses things.
- Is easily distracted.
- Is often forgetful in daily activities.
The child has to exhibit these symptoms in at least two out of three areas of life: home, social settings, or school. For school-age boys, that usually means home and school. In order to elicit feedback from schools, doctors provide teachers with a checklist of behaviors: often fidgets with hands or feet, often runs about or climbs excessively, often has difficulty playing quietly, often fails to give close attention to details or makes mistakes in schoolwork. In a quiet moment between classes, a teacher reviews the behavior of one of her or his one hundred or so students and checks off “Never,” “Rarely,” “Sometimes,” “Often,” or “Always.” After talking to the parent and to the child and reviewing the checklist, psychologists and physicians interpret the checklist to determine if a boy is “normal” or not.
How important is the teacher’s input? Bryan Goodman, a spokesman for Children and Adults with Attention Deficit/Hyperactivity Disorder (CHADD), a support group funded in part by drug companies that make popular attention-enhancing drugs, says, “Our position is that only medical professionals should make a diagnosis for ADHD. But teachers do provide crucial information that parents can then take to medical professionals.”
But not too much information. For a time, teachers, backed by eager drug company marketers, were playing too big a role in getting kids identified, diagnosed, and put on medication. In 2003, when Jonah Hoover attended first grade in Memphis, his teacher called in his parents, Brian and Kate, to discuss Jonah’s pattern of behavioral infractions: horsing around in the hallways, talking out of turn, and poking other kids. Recently, he’d gotten two half-day suspensions: one for squirting a ketchup packet at another kid, another for jumping in a puddle. “Exactly the same kind of stuff I did when I was a boy,” says Brian, who works in retail. The assistant principal was there, too. He lectured the Hoovers on the school’s code of behavior, then concluded their brief meeting by handing Kate and Brian a promotional pamphlet and DVD about Ritalin. “I had a pretty emotional reaction,” says Brian. “My son was six. I think long and hard before I give him an aspirin.”
This scenario was repeated so many times in so many schools that in 2003 a federal law was enacted to prevent schools from discussing ADHD medication with families — or risk having their federal funding yanked.
Bryan Goodman, the spokesman for CHADD, says, “We hear rumors about [schools pressuring parents to drug their children] all of the time, but we rarely find cases of it. What we do find are parents who spend years trying to figure out what the teachers are trying to communicate because of the rules of what teachers can and cannot say.” To that end, many teachers and school administrators point out that they have been carefully trained NOT to suggest to a parent that a child might have an attention problem or require medication. But the Farquhars and Hoovers and scores of parents like them from all over the country are not hard to find. They tell harrowing stories about teachers who repeatedly hint, suggest, insist, and even demand that parents give their kids — usually their sons — drugs.
What gives? I’m not sure. Some principals, school nurses, and teachers may be going out on an ethical limb, violating federal law and school policy because they have very real concerns that a child has a serious lifelong mental condition and they feel compelled to help. But what teachers and principals see as a gentle suggestion might be being interpreted by parents as a requirement.
“Parents really see teachers as having a medial authority,” says Dr. Ilina Singh, a lecturer at the London School of Economics, who studies ADHD. “Parents find it hard to resist a statement from a teacher concerning the normality of their child. In my experience, parents take it very seriously.”
What parents, psychologists, and physicians forget is that when a teacher checks off “Often” next to “Climbs excessively” she is saying something about your son but she is saying more about her expectations for your son’s behavior in her class. As schools ratchet up their expectations, says Lawrence Diller, a psychiatrist in the Bay Area who has been an outspoken critic of the ADHD industry, “more kids — and particularly more boys — look as if they might have a problem. Teachers now demand a standardized level of performance from all students. Many can’t tolerate too much motion, too much noise, too many questions — even within the range of normal — if it interferes with the pace of their class. They forget what’s normal.”
Then there are kids who won’t pay attention. Diller says, “For most kids, there is a natural downturn in motivation as they approach middle school. Kids who have been trained in good habits weather the change with no problems in school. For others, who by nature or nurture have not developed good habits” — Diller estimates their numbers to be about one in five — “school performance plummets.” And that puts them under stress. “When girls are under increased stress, they fold their hands and get quieter. When boys are under stress, they become a behavior problem.” If their parents are wealthy enough, the boys end up in Diller’s Walnut Creek office, where Diller says he produces medically enhanced compliance in those boys by providing them with attention-enhancing drugs.
“Do I like it?” he asks. “No. But I do it. And as a consequence, I feel compelled to speak about it publicly.”
A teacher’s opinion of your son’s behavior is a subjective one. When it comes to identifying boys with ADHD, it turns out the teacher is often wrong. In 2005, psychologist J. Michael Havey and his team from Eastern Illinois University surveyed 52 regular K–6 classroom teachers from eight different rural midwestern elementary and middle schools. Most of the teachers were experienced; 35 percent of them had been on the job over twenty years. Havey asked them to fill out a questionnaire on ADHD in the classroom and then complete a rating scale on 121 randomly selected boys and girls to identify the ones who they thought were suffering from the disorder. In the opinion of these experienced, well-meaning teachers, 24 of the 66 males they evaluated had ADHD. Other studies have found that teachers from private schools, and teachers with large classes where maintaining order in the classroom is key, also report implausibly high rates of ADHD. Guess who gets identified (wrongly) most often? Boys.
Small changes, big results
Some experts say that instead of medicating boys, it may be time to change some of the routines of schooling. Lisen Stromberg, a former ad agency executive from Northern California, says she’s trying. A few years ago, she founded an advocacy group called Save Our Sons in Northern California in an effort to encourage schools to be more tolerant of typical boy behavior. “All my friends who had active boys were being told, ‘This boy is out of control. This boy needs to go on Ritalin right away,’ ” recalls Stromberg. So she began to raise money — almost $600,000 in all — and launched a series of training sessions for teachers hoping to get the best out of their young male students. One hundred forty-six teachers from public and private schools in Northern California attended. “We started with the idea of helping teachers understand the gestalt of a boy — what makes up the boy dynamic, the bandwidth of boy behaviors, how boys interact, and about boys’ cognitive and physical needs,” says Stromberg.
The training continues to have a big impact on teachers at the Ohlone Elementary School, a public school in Palo Alto, California. As is so often the case in any discussion of schoolboys, the link between well-being and movement was front and center. “The way schools are run we have kids sitting at desks for a very long time,” says principal Susan Charles. So Charles and her teachers began changing how things were done. If a kid wanted to stand instead of sit while he wrote, no problem. If he was wiggly during circle time, he got something to lean against. Poor fine motor skills? He got a fat pencil to hold instead of a thin one. The changes cost nothing, says Charles. “Sending a child out for a run break costs nothing. Allowing them to work outside instead of at a hard table costs nothing. You have to change the mindset of the school and what it should look like.” Does ADHD exist there? Sure. But the principal and teachers at Ohlone want to make sure the school environment isn’t part of the problem.
Of course, you want to give your son the tools he needs to do well in school — and that’s especially true if your child is struggling. Your son may be suffering from ADHD, but remember that teachers aren’t always the best people to make that diagnosis. Sometimes, the school, not the boy, needs the overhaul.
Excerpted from "The Trouble with Boys" by Peg Tyre. Reprinted with permission from Crown, a division of Random House, Inc. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.