Politically totalitarian, physiologically inhumane and reminiscent of Stalin’s Russia. These are the views recently published by the British Psychological Society’s educational and child psychology division on medicating children diagnosed with attention deficit hyperactivity disorder (ADHD).
It’s an opinion that some in education will no doubt share but it is one that worries Ilina Singh, professor of neuroscience and society at the University of Oxford.
“This misguided statement prioritises provocative rhetoric over thoughtfulness, respect and care for those families and children,” she says.
She points out that the National Institute for Health and Care Excellence (Nice) doesn’t recommend stimulants as a first-line treatment option for children with ADHD in the UK and that, contrary to the views of many, the use of ADHD medication in this country is not that common.
“Use of ADHD medications in the UK is consistently estimated to be among the lowest in the world, and low relative to overall UK ADHD prevalence estimates. The numbers do not suggest an evil totalitarian plot against UK children,” she says.
Singh encounters what she believes to be misinformation around ADHD frequently in her work: ADHD tends to be a polarising topic, with opinion quickly cited as fact. This is particularly true in education. Singh knows the arguments well; she began researching the condition in the late 1990s.
“My topic was parents’ experience of diagnosis and medication of kids with ADHD. At the time, in the US, kids were just beginning to be prescribed stimulant medication like Ritalin,” she says. “From a medical perspective, it was seen as a good thing. Kids were responding well to treatment. But from a societal perspective, it was seen as worrying. So my idea was to talk to parents about their decisions to put their children on medication.”
Damaging myths around ADHD
She soon encountered one of the most prominent and most damaging myths around ADHD: that it is just bad parenting and the condition does not really exist.
“There was a view that mothers put their children on medication to feel better about themselves. When a young boy – at the time it was mainly boys diagnosed with ADHD, and it still is – starts behaving this way, the first look is to the mother. And that causes a lot of distress for those mothers. And with the fathers, I found that many of them felt genetically culpable for their child’s diagnosis. They talked a lot about their own histories, identifying with their boy’s behaviours and they felt a biological culpability,” Singh says. “I think it’s a shame that we blame parents, particularly mothers, for so much that goes on with our kids.”
The reason the “existence” issue arises around ADHD is the lack of biological markers to define diagnosis, she explains.
“ADHD is a spectrum disorder, existing from mild to severe,” she says. “We don’t have good markers. We use subjective measures, questionnaires, self-report, so there isn’t enough objectivity in the diagnosis. A lot of people say, ‘Well, that’s why all these kids are being diagnosed with ADHD.’”
But she says that she has spent enough time with families and children affected by diagnosis to know where she stands on how “real” the disorder is, and she is certain it needs close attention in schools.
“At the mild end of the spectrum, we could do more for children so that they are managed environmentally through more understanding classrooms, better organisation and control of their behaviour at home,” she says. “At the severe end, if kids are impaired enough that they need medical attention, it doesn’t have to be medication, but it needs to be managed somehow, then I think the best system for managing ADHD is in medicine.”
Singh wanted to get to the heart of what it is to be diagnosed with ADHD – the impact on a child’s sense of self, their morals, the stigma – by speaking to children themselves, but there was reticence from funders.
“When I moved to the UK, I tried several times to get funding for such a project and I failed, because I kept being told, ‘They’re kids. They can’t speak about ethics and morals.’ I had to show that I could develop tools that would allow children to engage in research questions,” she says.
Eventually, her project Voices (Voices on Identity, Childhood, Ethics and Stimulants: children join the debate) was born. With funding from the Wellcome Trust, Singh and colleagues interviewed 151 children aged between 9 and 14, along with their families, in both the US and UK. Interviewees spoke about their first-hand experiences of ADHD diagnosis and stimulant drug medication. The report was published in 2012.
In the study, Singh explored some of the most common criticisms levelled at medicating ADHD children.
“First, that medication would turn kids into robots, taking away their moral agency. Secondly, that it would violate their sense of personal authenticity – who they really are. Finally, that drugs would undermine the child’s ability to learn about personal responsibility, allowing them to blame their brain, their medication, their diagnosis, rather than take responsibility for their actions,” she says.
In fact, Singh found that many ADHD children felt that medication improved their capacity to make a call between doing right and wrong. Here’s an example.
“One scenario we heard a lot about in the school context was bullying. Children with ADHD engage in behaviours – inattention, distraction, hyperactivity – that get them into trouble a lot. So in the playground, their peers go out of their way to wind up these kids. Medication helped ADHD children to slow down, to think about how they wanted to respond. They might still respond by physically or verbally attacking another child, but they felt they could make that decision. They were agents of their own behaviour,” she says.
And playground culture is an area that she feels often gets overlooked.
“These kids go out at lunchtime and they get bullied or they bully,” she argues. “[They] report that they feel more comfortable in playgrounds that offer a range of options for physical and creative play, perhaps because this keeps other children occupied.”
And what of the classroom? How can teachers manage children with challenging behavioural symptoms while trying to get on with the job of teaching?
Singh highlights the “red light classroom management system” as working successfully in US primary schools.
“Rather than publicly shaming the child or calling them out on challenging behaviour, it’s about putting a red, amber or green piece of paper down on their desk. So the red piece of paper might mean that the child’s behaviour isn’t acceptable and they should go out into the hallway and take a few minutes to themselves. I think that kind of communication, which is respectful rather than demeaning, can be really empowering to a child and teach them to evaluate their behaviour,” she says.
Other recommendations include allowing children with ADHD to have a “fiddle toy”, like a stress ball, in the classroom. “Explain the rules of how this is to be used to the child or whole class,” she advises. “Put a toy on your desk that a child can retrieve, signalling that he or she needs to go to a ‘bean bag’ or reading corner for a five-minute break.”
And she says that focusing on the positive behaviour of the child is crucial.
“Praise is important,” she stresses. “Give an ADHD child a task they are responsible for every day, such as taking the register back to the main office. This gives you an opportunity to make eye contact and thank that child for doing a good job,” says Singh.
She is also passionate about ensuring that a child with ADHD has a ‘buddy’.
“A lot of these kids don’t have friends because they’re difficult for their peers, so if there is a peer who can gently help the child to manage their behaviour, help them stay calm and get focused, I think that would be very helpful,” she says.
Finally, Singh says that mindfulness could help children with ADHD symptoms. “While our research is inconclusive, when we spoke to kids about what they spontaneously do to help themselves, they would very often talk about meditative qualities,” she says. “The data does suggest – although it’s not great data – that mindfulness can work well for these kids, and for teachers.”
Ultimately, Singh believes that a holistic approach to educational strategy is needed, with everyone working together as a team – parents, teachers, medical professionals and, crucially, the children themselves, who are too often overlooked.
Christina Quaine is a freelance journalist