Pills to help poor children in poor schools

Suppose the problem really is in the environment, but you can medicate your child to help them cope. A lot of people may medicate themselves to help them through a bad situation. Facing an MRI in a closed machine (i.e., you’re in the clanging tunnel for possibly an hour)? Xanax can seem reasonable if you are claustrophobic. A wedding with your most difficult relatives? Maybe xanax there too, or a martini or whatever. How about a bad work situation? A pill a day to keep anger away?

For myself I’d say absolutely not in the last case (clarification added in light of comment one). For a healthy child with a poor school environment that makes concentration and learning really too hard? C/D unmedicated, A/B on pills. I feel fortunate not to have to decide this one. Some people do have tO choose between these alternatives:

CANTON, Ga. — When Dr. Michael Anderson hears about his low-income patients struggling in elementary school, he usually gives them a taste of some powerful medicine: Adderall.

The pills boost focus and impulse control in children with attention deficit hyperactivity disorder. Although A.D.H.D is the diagnosis Dr. Anderson makes, he calls the disorder “made up” and “an excuse” to prescribe the pills to treat what he considers the children’s true ill — poor academic performance in inadequate schools.

“I don’t have a whole lot of choice,” said Dr. Anderson, a pediatrician for many poor families in Cherokee County, north of Atlanta. “We’ve decided as a society that it’s too expensive to modify the kid’s environment. So we have to modify the kid.”

Dr. Anderson is one of the more outspoken proponents of an idea that is gaining interest among some physicians. They are prescribing stimulants to struggling students in schools starved of extra money — not to treat A.D.H.D., necessarily, but to boost their academic performance.

It is not yet clear whether Dr. Anderson is representative of a widening trend. But some experts note that as wealthy students abuse stimulants to raise already-good grades in colleges and high schools, the medications are being used on low-income elementary school children with faltering grades and parents eager to see them succeed.

“We as a society have been unwilling to invest in very effective nonpharmaceutical interventions for these children and their families,” said Dr. Ramesh Raghavan, a child mental-health services researcher at Washington University in St. Louis and an expert in prescription drug use among low-income children. “We are effectively forcing local community psychiatrists to use the only tool at their disposal, which is psychotropic medications.”

Dr. Nancy Rappaport, a child psychiatrist in Cambridge, Mass., who works primarily with lower-income children and their schools, added: “We are seeing this more and more. We are using a chemical straitjacket instead of doing things that are just as important to also do, sometimes more.”

17 thoughts on “Pills to help poor children in poor schools

  1. I think you are too quick to dismiss medicating to deal with stressful circumstances (at the top). If the medicating of children in bad environments is justified because it helps them, then the same kind of consequentialist analysis will, at least sometimes, warrant the Xanax or the martini.

  2. ChrisTs., thanks so much for your comment. I meant the ‘not’ only to cover the last case. I couldn’t bear a closed MRI without xanax, and a good martini seems to me quite ok as a way of dealing with the awful relative, though by this stage of my life I’ve acquired some other responses. Well, I sometimes have other responses.

    I still don’t knowing about years of pills for kids.

  3. I don’t know why the word ‘pill’ is magical for people. What if we found out that eating tons of spinach raised grades substantially? Wouldn’t we make kids eat tons of spinach? Now what if were Vitamin C that did that? Wouldn’t we give kids Vitamin C? Of course, we should also, even primarily, be worrying about a structurally problematic and unjust environment. And of course we also don’t trust big pharma to be straight with us about side effects and the like. (Not that I trust the ‘natural supplement’ wing of Big Pharma, or the Big Farma spinach industry, any more.) But the mere fact that they are pills, or ‘drugs’, seems uninteresting to me. All else being equal (which it never is), if ingesting a substance has good effects, I don’t see the problem with giving it to people.

  4. I agree with Rebecca that we are often far too quick to decide that a treatment is extreme, dangerous, or ethically problematic just because it is in pill form. In particular the reaction of some people to stimulant medications for ADHD is hyperbolic, irrational, and ill-informed.

    However, having had experience with both Spinach and ADHD meds, I would say we do have some reasons to treat the former with greater caution–reasons that are somewhat more interesting than the fact that adderall comes in pill form. ADHD meds can have a powerful and immediate effect on one’s mental and emotional life, among other things. For me, taking adderall has been a very positive force in my life. But it was a tradeoff and I’m glad I got to make the decision for myself as an adult. That is not say that we should never give kids stimulant medication. The consequences of untreated ADHD often far outweigh the downsides of medication. It is only to say that it is not a decision to be made lightly and kids should always be included in the decision process as much as possible.

    I want to stress that although stimulant medication does have significant and diverse effects on its users, its effects are often not what some people tend to think they are. For example, this article quotes Dr. Rappaport as referring to stimulant medications as a “chemical straightjacket.” I often hear people suggest that they turn their users into zombies or automata. The way some talk, you would think we were talking about Ketamine. Everyone’s experience is different, and one’s experience will vary with dosage and other factors, but this depiction does not fit my experience at all. To the contrary, I found stimulant medication to be empowering. I could suddenly do things that I couldn’t before—some, like writing philosophy and communicating with others effectively, were incredibly important to me. I remember the first time I tried it, I remarked, “it’s like I finally have access to my own thoughts!”

    I think these alternative understandings of the effects of stimulant medications bears heavily on whether the treatment described in this article is ethical. It is the difference between controlling deviant behavior caused by the students’ circumstances and giving the students tools that will help them cope with their circumstances.

  5. Zombie, your internet handle somewhat pushes against the content of your point :)

    More seriously, I of course agree that there are more reasons to be wary of Adderall than spinach. I just don’t think that the fact that it is a ‘pill’ or a ‘drug’ has anything to do with that. Anyhow thanks for your thoughtful and helpful post.

  6. So much to say.

    Currently, I teach job skills training to clients on TANF (aka welfare). There are many shocking things that I hear everyday, but a few things have stuck out:

    1: if I had to guess, I’d say 70-80% of my clients say their kids had ADD/ADHD. Probably 30-40% of my clients cite the same for themselves.
    2: Schools are *diagnosing* children with ADD/ADHD. (What?! When did this start happening?)
    3: It also seems that for many people who don’t truly need these particular kinds of pharmaceuticals, the drugs can definitely be a (I’m loathe to use this word) gateway drug to meth. Something that certainly should be a factor in discussions about what to do in economically disadvantaged education systems.

    Last but not least, If I choose to self-medicate because of a bad working situation, that’s one thing. Children obviously don’t have that same autonomy over their still-developing brains.

  7. I suppose one worry is that by using medication in this way, you remove at least one incentive to improve schools and other facilities: the poor performance of the relevant group of children. I can’t see that this has been an effective incentive to improve schools in the past, however, so it doesn’t seem like an incentive that’s worth sacrificing the boost in performance from medications for (though this could turn out to be wrong on the evidence).

    But the worry expressed in this article is more like ‘we use drugs because the schools aren’t good enough’. I can see why that could look like an argument for improving the schools (insofar as it basically says: the schools are bad!), but not a reason to stop using the drugs. In fact, suppose we have three alternatives: (i) improve the schools to get educational outcome A at cost C, (ii) don’t improve the schools but medicate to get outcome A for a cost less than C, and (iii) improve the schools and medicate to get a better outcome than A. Assuming that improvements from medications don’t start to become more costly than school investments the better the outcomes get, it looks like (iii) is better than (ii) is better than (i). So we shouldn’t stop medicating in any case. It might even turn out to be more effective to invest in finding better cognitive enhancers than investing in improving failing schools!

    It also seems like cognitive enhancers have great potential to reduce inequality, given the correlations between success and things like conscientiousness and IQ, assuming the effects are more pronounced among those who are worse off to begin with (or if we can reach a point where one can select the degrees to which we have these traits). Unless you’re anti-egalitarian, it seems strange to object to their use in poorly performing children if you’re happy about their use among the already top-performing students, which seems fairly widespread. And most people, in my experience at least, seem fairly tolerant of the latter.

  8. Rebecca, your reaction surprises me. There seem to be a number of reasons why one might sense a negative implication in the Times headline, which was something liked “ADHA or Not, Pill for school kids.”

    1. A general suspicion of pills.
    2. The conversational implicature: if it’s on the front page of the NY Times, it is probably not about something quite obviously harmless and not really worth bothering about.
    3. The context: There’s been a lot of concern over the last several years that we are saying some children have serious psychological problems and giving them powerful psychological drugs when it may well be the school environment and/or home environment that needs changing. And now we’re thinking of giving the meds to kids who do not have ADHD.

    2 and 3 seem to be the more plausible interpretive hypotheses.

    And the medication mentioned is serious:

    Amphetamine and dextroamphetamine is a central nervous system stimulant. It affects chemicals in the brain and nerves that contribute to hyperactivity and impulse control.
    Amphetamine and dextroamphetamine is used to treat narcolepsy and attention deficit hyperactivity disorder (ADHD).

    Amphetamine and dextroamphetamine may also be used for other purposes not listed in this medication guide….

    Used over time, it may delay growth in children….

    It also appears to affect the thyroid and the heart, though not to a dangerous extent in the absence of a pre-existing condition.

    This info comes from a site the noted hospital, MD Anderson, sends people to, so it seems to be reliable.

    I really, really dislike the idea that perfectly healthy “normal” kids end up experiencing being under the influence of amphetamines as a regular part of life so that they can deal more effectively with a really bad educational environment. I grew up at a time when amphetamines were regarded as a cure all. Fatigue induced by medicine for endometriosis? Have some amphetamines. Gained weight your first year at college? have some amphetamines. What to have a really scary hallucination? Well, on those amphetamines you just might, and I did. I mean, a genuine hallucination, as though a huge siren was going off under my bed.

  9. My dislike does not mean I wouldn’t use it. I am just so glad I don’t have that decision. On the other hand, I tried for the last year and more to get a relative to use a much more serious psychological medication, since the alternative was living in a delusional world, which he no longer does, since he is taking the meds. Perhaps going through school without learning much at all should seem as seriously crippling. Still, the real problem is not in the kid, as it was in my relative.

  10. The problem is surely not in either the agent or the environment, but arises from the interaction of the two things. And this doesn’t seem to justify privilaging either as the thing we should change. If we could make the world such that the delusions of an agent were in no way problematic for her, then that would solve the problem. So too would removing the delusions and keeping the world fixed. Similarly, if we have a child that’s doing badly in school, then we can either change the school or change the child in order to solve the problem. But the problem seems to lie no more in the school than it does in the child – we just need to figure out which fix is more efficient.

  11. Amanda, I’m not sure why you think the following is true: “The problem is surely not in either the agent or the environment, but arises from the interaction of the two things.” Suppose one lives in a filthy environment and needs to take antibiotics all the time to stay well. There seems to be a clear sense in which some problem arises from one living there, but “the problem”, that is, what needs to be fixed, is the filth.

    The claim of all these people being interviewed is that the problem with the schools is like the problem with the filth. Of course, perhaps one could solve the problem by moving, but with poor people getting the child into a better school isn’t possible, apparently.

    Of course, one might say: well, not everyone gets sick all the time in a filthy environment, so there’s something else going on. Perhaps, but given the problem is solved when the filth is clean out, there seems good reason to lament that one is having to take the antibios.

  12. The prblems in the filth case you described are, let’s say, being ill and living in an environment that makes you sad. We can remedy those problems in many ways. For example, if we had antibiotics that prevented the relevant illnesses and another drug that made living in a filthy environment make you happy rathere than sad, then that solves both problems. And removing the filth is another way of solving both problems. But ‘the problem’ (i.e. the source of the bad outcomes described) isn’t the filthy environment, it’s the fact that agents like us are living in a filthy environment. After all, the filthy environment presumably wouldn’t be the source of a problem at all if it were only populated by filth-loving insects. One way to solve the problems that arise from humans living in filth is to change properties of the environment, and another is to change properties of the humans. But I still don’t see any reason to privilege either solution (prior to having any information about the efficiency of each), or to call the filth the mainsource of the problem any more than we call the people’s dislike of filth and filth-effected immune systems the main source of the problem.

    Similarly, in the school case, the source of the problem (bad educational outcomes) doesn’t seem to be the school or the child, but the fact that a child with properties X is in school with properties Y. We can change the properties of the school and/or we can change the properties of the child. If doing the latter turns out to be more efficient the former (taking into account bad incentives and externalities) then it seems to be the best way to solve the source of the problem.

  13. Amanda, I didn’t say anything about being sick before hand and sad.

    I think the considerations you adduce are at least close to those that come with trying to find “the cause”. There may be, depending on our interests, many different factors that could be called the cause of, e.g., a house fire. Similarly, there are many different things that could be called “the problem” in the school case we’re looking at. There’s isn’t a metaphysical solution that will allow us to understand all the things people are correctly after when they talk about the cause. For example, one candidate in the school case would be that the parents are poor, and that might be due to one of them having some expensive illness. For them, they might say, the problem is really the medical bills.

    So usually when people are talking about what the problem is, they have some background standard or set of interests. In this case, people seem to have an idea of what sort of schools ought to be provided, what communities ought to do to provide them, and also what’s a good way to solve the children’s poor performance. In short, they seem to be looking at what is the biggest adult failure. Is it that the parents are not medicating their children or is it that in poor neighborhoods, people do not have the resources – and the government doesn’t have the will – to fix the schools? That’s why they, and I, are all inclined to say the failure is the failure to fix the schools. That’s the problem.

  14. With the sick and sad assumptions, I was just trying to differentiate between the bad outcomes and the state of affairs that gives rise to those outcomes, since we can sometimes use the word ‘problem’ to mean both of these things. The thing that needs to be fixed seems to be the bad outcomes, and altering the state of affairs is merely a means to doing this. Perhaps the analysis of the underlying problem I give will be similar to a causal analysis under certain accounts of causation, but it’s really just trying to capture the most relevant factors that would, if altered now, alter the outcome. We can imagine some past event that produced the filth or produced the current education system that would be treated as irrelevant under the analysis of ‘the problem’ that I gave, but might nonetheless be a cause of the bad outcomes.

    In any case, I think you’re right to say that people usually hold certain things fixed when they talk about what ‘the problem’ is. My worry is that we often shouldn’t be doing this, for a couple of reasons. Firstly, the choice of what to hold fixed (e.g. holding the properties of the child fixed rather than the properties of the school) seems somewhat arbitrary. And, secondly, by treating both factors in a case like this as ‘the problem’ we open the door to solutions that might seem atypical, but actually turn out to be better for everyone involved.

  15. @Anne at #1:

    Even wit respect to the bad work situation, I don’t think we should be quick to dismiss medication as a solution. It might be a temporary one (I’ve been through that with a colleague who just… lost it) or it might be long term.

    In either case, the question is whether there are better and feasible alternatives. If there are not, then medication might be the best available way of defending oneself against stress or depression.

    I do think that in the case of children there are serious complicating issues. First, there is their lack of agency in the whole decision making process. Second, there is the possibility of long-term effects of which *no one* is fully cognizant. Perhaps the natural role of parents answers the first, but I think the second is not taken care of so easily.

  16. ChrisTS, I meant only to be speaking for myself.

    I think it might be wise to avoid xanax on a long term. But in fact maybeprobably a lot of people take some drugs to cope with ordinary life. I think I was thinking of situations which go pretty far beyond acceptable, such as mobbing.

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