For kids with attention deficit
hyperactivity disorder (ADHD), the return to school
often heralds the end of their drug holiday and a return
to daily psychostimulants. Use of these drugs in schoolkids
has risen sharply — in Canada, methylphenidate
prescriptions rose by 500% between 1990 and 1997, according
to Health Canada. Some people contend teachers are becoming
more and more aggressive in demanding 'bad' children
go on these meds, or else face suspension, and that
doctors are only too willing to go along.
"This shouldn't surprise us," says
Dr Christine Phillips, GP and senior lecturer in social
foundations of medicine, Australian National University
Medical School. "Much concern about the condition arises
within the school and is related to performance issues
that are to do with schooling." But where does that
leave MDs in the diagnostic chain of command?
NEW
ROLE, SAME PAY
Dr Phillips wrote about the issue in the April 2006
PLoS Medicine in an article entitled "Medicine Goes
to School: Teachers as Sickness Brokers for ADHD." Teachers
are the first ones to notice behavioural problems from
ADHD, she says. On top of spotting, they assist formally
in the diagnosis, using DSM-IV-mandated tools like the
Conners Teachers rating scale. If meds are prescribed,
they may even dish out daily doses to forgetful kids.
But have teachers been thrust into a healthcare role
they're ill-equipped to handle?
Drugs to treat ADHD aren't exactly
benign. They can cause loss of appetite, insomnia and
stunted growth (which is why many docs recommend kids
go off the meds during the summer). "You have to balance
the risk posed by giving the medication, and the risks
posed by not giving it," says Dr Lily Hechtman, director
of ADHD research at the Montreal Children's Hospital.
But mitigating the symptoms and
side effects is the doctor's job, not the teacher's.
And physicians by and large feel that they're in control
of the situation and are not being dictated to by teachers
or parents.
Teachers, parents and physicians
consider the drugs as indispensable tools, suggesting
it's more a case of good disease recognition. "The behavioural
improvement in kids correctly diagnosed is significant,"
says Dr Hechtman. "In the past these patients were not
identified, and not treated."
SICKNESS
SIEVE
"There is, if anything, reluctance from teachers and
parents to push medication," says Dr Hechtman. Teachers
will try many behavioural interventions in children
identified as problematic, before any prescriptions
are written. These efforts root out kids for whom the
medications aren't appropriate, and could include tracking
of their class-to-class conduct, and switching children
to different seats, classes and schedules. Teachers,
nurses, social workers and principals will all be involved
if the school suggests the child visit their pediatrician.
"We never see the kids that improve
with other measures," says Dr Hechtman. "When a child
finally reaches the pediatrician, low IQ, birth and
development history, medical problems like petit mal
epilepsy, hyperthyroid, hearing and vision problems
are all further ruled out."
In kids whose behaviour doesn't
improve, a cycle of poor behaviour and reprimand may,
at worst, eventually lead teachers to refuse to teach
the child. This has in the past led schools to mandate
psychostimulant use or the child will be expelled.
That's what happened to Gabriel
Lavigueur, a grade seven student from Longueuil, near
Montreal. Last school year his mother Danielle says
Gabriel was expelled from his school after he went off
his ADHD meds. He had previously committed to taking
the drugs in an agreement worked out between him, his
mother and the school. When he stopped using them because
of side effects, including insomnia, loss of appetite
and aggressiveness, he was booted from school for bad
behaviour. The school board denies it forced the child
to take methylphenidate and contends Ms Lavigueur pulled
him from school herself.
Although school-mandated drug use
is rare there are arguments that more attention should
be paid to keep casual ADHD drug pushing out of the
schools. The case is now the subject of a class action
suit.
Dr Phillips says that teachers
are being targeted by drug firms the same way physicians
are. "Teachers are encouraged by pharmaceutical promotional
material to raise the possibility of a diagnosis with
parents, and to discuss management options," says Dr
Phillips.
Dr Phillips thinks teachers need
better education on these disorders and treatments.
As she wrote in PLoS, "teachers need to be supported
to be objective and accurate interpreters of information
for parents and healthworkers."
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