A New Crisis
The United States is one of the most medicated countries in the world with over half of the nation taking at least two prescription medications, a number that has been increasing steadily over the past decade. While prescription drugs can be a life-saving solution that helps Americans regain control over their physical and mental ailments, overprescription of unnecessary medications is no new story for the country. While many Americans associate overprescription with the years leading up to the opioid crisis and the addictions that followed, they ignore more common drugs being overprescribed in the present.
Today, there are two prescription drugs sweeping the nation: Adderall and Ritalin. These drugs are not only growing in popularity amongst adults—even children as young as two years old are being prescribed the drug at alarming rates. Adderall and Ritalin are stimulants widely known for their use and abuse on college campuses, but they are rarely discussed in terms of children’s usage. Despite American regulatory bodies like the FDA advising against the use of stimulants on toddlers, doctors continue to legally prescribe these stimulants to children aged two to six.
The overuse of stimulants is a new and evolving issue that arose almost synonymously with the rise of Generation Z (“Gen Z”). Gen Z was born between 1997 and 2012, during which the country saw significant growth in the amount of Adderall prescriptions for children, with a 5.7 million increase in prescriptions from 1996 to 1999 and a 700 percent increase in the number of children prescribed stimulants from 2000 to 2012.
While confounding factors like the decline in stigma around mental disabilities and more progressive approaches in modern medicine might lead some to believe the increase in prescriptions is due to more people being recognized as having ADHD, and thus properly treated for it, other factors involving national policies, lack of resources, and ease of access can better explain why stimulant use in children has exploded and how the use of stimulants is replacing proper treatment for many.
What are Stimulants?
At their core, stimulants are a class of drugs that, when introduced to the body, speed up a person’s messaging and processing within the brain. Stimulants include anything from caffeine to cocaine and can vary in their own severity and effects on a person. Most stimulant prescriptions are used to treat Attention-Deficit/Hyperactivity Disorder, or ADHD. In treating ADHD, doctors will commonly prescribe one of five stimulants: Ritalin (methylphenidate), Vyvanse (lisdexamfetamine), Adderall (mixed amphetamine salts), Dexedrine (dextroamphetamine), and Focalin (dexmethylphenidate).
In children though, Ritalin and Adderall are typically prescribed, both of which are considered schedule II controlled substances—substances defined as having “a high potential for abuse which may lead to severe psychological or physical dependence.” Other drugs in the schedule II family/categorization include cocaine, fentanyl, and methamphetamine.
How many children are actually being prescribed these drugs?
According to the CDC, 6.1 million children in the U.S are diagnosed with ADHD and, despite diagnoses for ADHD at young ages being hard to be certain of, a survey revealed that 388,000 of diagnosed children were between the ages of two and five years old. Of those toddlers, 18% are treated with medication. Should we be medicating children this young? Many normal behaviors of children can double as a symptom—impulsiveness, restlessness, fidgeting, etc—of ADHD, leading to a misdiagnosis when the child doesn’t have ADHD at all.
A 2014 report states that a minimum of one out of every 225 toddlers in the nation are medicated with stimulants like Adderall and Ritalin. One can only imagine how much that number has increased since, and with that many children nationwide taking these substances, it might be time to ask why.
Quick Fixes: The Toddler Case
The question of proper diagnosis is tricky—while signs of ADHD can begin at ages two and up, they can be heavily confounded with a variety of other lifestyle factors children in that age group may face as signs of ADHD can be eerily similar to traditional childlike behavior. To properly diagnose and treat children with ADHD, the CDC has established guidelines starting with evaluations at the ages of four to six. When properly diagnosed, behavioral therapy is the first line of treatment, followed by medicating through Ritalin when the behavioral interventions do not improve the child’s condition. Even though the CDC protocol technically greenlights the use of Ritalin when “serious problems” persist, the FDA has not approved the use of Ritalin for children under the age of six.
Sadly, the reality of these diagnoses is nowhere up to par with the CDC guidelines. A diagnosis can merely consist of a few, surface-level office visits where doctors throw prescriptions at parents to see if it improves their performance in school. This type of diagnosis is seen more commonly in families who lack access to necessary resources and cannot commit to consistent behavioral therapy due to full-time jobs or monetary restrictions. In fact, a doctor is more likely to prescribe stimulants for those ill-behaved children who are living under the poverty line as a prescription is a more simple solution than addressing a complicated home environment. Many of those children also rely on government programs like Medicaid, and it was found that for those on Medicaid the time for an average ADHD assessment was no more than a 10-minute office visit, vastly different from the series of evaluations and continual demonstration of symptoms the CDC describes in their guidelines for diagnosis.
Complex issues and stressful home environments are common among children diagnosed with ADHD, making it difficult for children to be accurately diagnosed at a young age. The symptoms noted when toddlers are diagnosed include inattention, hyperactivity, and impulsivity—all behaviors that aren’t inherently abnormal for children in the two to five age range. A study from the National Institute of Mental Health showed that three-quarters of children with ADHD outgrow their condition by their mid-twenties, providing significant evidence that these diagnoses may be false. One cannot help but wonder if the diagnosed person actually has the genetic condition or if they are simply an energetic or stressed child given medication to ease the life of a parent.
There are many reasons why these stimulants are more prevalent now than they used to be; researchers draw connections to the legalization of drug advertisements on television where companies could now advertise their medication to the public. By making parents of hard-to-manage children aware of a possible solution for their problematic/difficult traits/aspects, these television ads encourage them to ask their doctor for ADHD medications, regardless of the child’s actual need. Even so, there is another, larger connection that seems to directly target children in America: consequential accountability in schools.
Consequential accountability is a “model of education reform [that] involves creating explicit standards for students, testing against those standards, and assigning consequences to schools for failure to meet those standards.” This model was introduced to schools in the ’90s and was brought to the national level through No Child Left Behind, or NCLB, in 2002. NCLB was a nationwide initiative that forced schools to prioritize standardized testing where their funding would be reliant on the rates their students passed the nationwide exams. While the program has had many adverse consequences since its passing, the significant increase in ADHD diagnoses that followed is one that is not often discussed.
A study done by UC Berkeley Professor Stephan Hinshaw discovered that the rates of ADHD diagnosis had a 22 percent increase in the first four years following the implementation of No Child Left Behind. Even worse, this continues to disproportionately affect underprivileged children in America. Between 2003-2007, in 20 states that did not receive consequential accountability until the implementation of NCLB, there was an approximately 60 percent increase in the number of ADHD diagnoses among children who were within the federal poverty limit.
Two actors substantiate the connection between consequential action and Adderall prescriptions: First, the standardized testing process is incredibly unnatural for students—especially younger ones who are being forced to sit for multiple hour-long exams without breaks. Secondly, the benefits schools receive for diagnosing ill-performing students with ADHD allow those students to be removed from the states’ pool used to judge their performance in accordance with NCLB.
The American public school system incentivizes children to spend more time working and less time being kids.
Hinshaw is quoted as saying “During the same 30 years when A.D.H.D. diagnoses increased, American childhood drastically changed. Even at the grade-school level, kids now have more homework, less recess and a lot less unstructured free time to relax and play. It’s easy to look at that situation and speculate how ‘A.D.H.D.’ might have become a convenient societal catchall for what happens when kids are expected to be miniature adults.”
Smart Pills: The College Case
If American toddlers manage to escape childhood without an Adderall prescription, it’s hard to say they won’t find themselves taking it in college. Despite the fact that anywhere from two to eight percent of college students are diagnosed with ADHD, surveys have found that approximately one in six students in college have claimed to have used these stimulants. With the intense workloads demanded of colleges for students, many turn to stimulants like coffee or caffeine pills. But when those aren’t enough, Adderall can be easier to find than mustering up the energy to focus naturally. Many students even find themselves at a disadvantage without taking the drug; academic environments where everyone uses stimulants as performance enhancers can leave many non-users left behind.
While it may seem nearly impossible to regulate the types of drugs college students may have access to—any student with a prescription could be illegally sharing their unused doses— it doesn’t mean we have to ignore how easy it can be for just any student to receive an unnecessary prescription from a medical professional.
In a 2016 New York Times feature, Casey Schwartz, a college student, describes their experience of abusing Adderall to advance in academics, leading to an ER trip after they experienced an amphetamine-induced panic attack.
“I was sitting in exactly the kind of place I had envisioned, an impersonal room with gray walls and black leather furniture, describing to the attractive young psychiatrist in the chair opposite me how I had always had to develop elaborate compensatory strategies for getting through my school work, how staying with any one thing was a challenge for me, how I was best at jobs that required elaborate multitasking, like waitressing. Untrue, all of it. I was a focused student and a terrible waitress. And yet these were the answers that I discovered from the briefest online research were characteristic of the A.D.H.D. diagnostic criteria. These were the answers they were looking for in order to pick up their pens and write down “Adderall, 20 mg, once a day” on their prescription pads. So these were the answers I gave.”
For doctors, it can be almost impossible to make distinctions between those students who need the stimulants and those who don’t, and there are plenty of students who take advantage of this challenge to be falsely prescribed the drug in hopes of improving their grades.
The over-prescription and ease of access to Adderall and similar stimulants are perfectly legal and utilized by pediatricians and doctors across the nation. Like any commonly abused drug, there need to be regulations on how doctors prescribe them and proper monitoring of the patient’s intake, refills, and behaviors to ensure abuse isn’t occurring.
ADHD can be a debilitating and frustrating ailment that affects many across the country. The mainstream discussion and normalization have helped greatly to destigmatize the idea of medicating for mental health and is a trend that should continue and spread to other forms of mental illnesses. Despite the flaws and stigma surrounding Adderall and other stimulants, they do serve a major benefit for those who need it and can be life-changing in helping people overcome their struggles and gain control of their life. In fact, the use of stimulants along with behavioral therapy or treatment has proven to be the best and most effective way to treat ADHD. The issue lies with the over-prescription of stimulants under the assumption of ADHD without proper diagnosis or evaluation/evaluation for an accurate diagnosis.
These stimulants most simply are not designed for those who do not need them, and the abuse and dependence people face once they rely on them from a young age or to combat large workloads needs to be addressed and adequately handled both through policy and by individual doctors and practices nationally.
Featured Image: Image edited by Alexis Mariash, Original Image from Aleksandar Pasaric