Friday, February 13, 2015

Hume vs. Crank

Methylphenidate has been FDA-approved since 1955, and has been used to treat hyperactivity (the ADHD family of disorders) for over half a century now. But it's only since the 90s that it's been so frequently prescribed to school-aged children to get them to settle down.

Is it euvoluntary to stuff ornery brats full of Ritalin?

When I was in grade school, the convention was "no." Kids took prescription drugs for serious illnesses (and yes, right-tail ADHD is indeed a serious illness) only. If you were fidgety, the teacher told you to shut up and sit still. Recess was the time of day to burn off the jibblies. But now? Conventions have shifted. It is, evidently, no longer outrageous that the ADHD diagnosis threshold has become less rigorous (though, to be fair, the prescription rate of 5.4% of students is dwarfed by the nearly 18% of students who report having taken some sort of prescription drug without a prescription). Still, as a rough guideline, when I was in elementary school, I could expect to find maybe one student in the entire school taking psych medication. Now, I can expect one student in each classroom to be on something. That's a substantial change.

Consider each of the parties to a Ritalin exchange.

The majors:

  • The teacher is better off, since having to deal with discipline problems the hard way takes valuable time away from preparing other students to meet standardized test requirements.
  • The student is better off, obtaining higher marks, which increase the probability of elite college admission and attendant higher lifetime earnings.
  • The parents are better off, what with the Instagram-ready little tykes dutifully doing their homework.
  • The physicians are better off. A few minutes of their time to bill against a diagnosis? There might be a risk of being found negligent for over-prescription, but AFAIK, there's been no big class action for ADHD yet and even if there were, that's what malpractice insurance is for, right?
  • Novartis (Mallinkrodt, Sandoz and Watson for generics) is better off. Particularly if their products are addictive.
The minors:
  • The sovereign. Obedient students make for obedient citizens (and obedient Soldiers/Praetorians). 
  • Employers. I found some observational studies, but long-term controlled experiments are harder to track down. Still, it appears that methylphenidate does affect brain development, producing adults with fewer ADHD symptoms, meaning that if you need to hire someone who can focus on repetitive tasks or work that demands attention, a history of taking meth lite might make a resume more attractive.
  • Other citizens. Paying attention behind the wheel, in the checkout queue, or in the tiny galaxy of other small daily interactions makes life flow more smoothly. Easily-distracted passers-by can be infuriating, particularly for overstarched uptight types (like myself).
Of course, there could be a wide range of hidden costs. Attention is great for rote tasks, for memorizing the dates of history, of solving differential equations, of reciting great speeches. It's great for conformity. And like I pointed out up top, there are genuinely people with severe ADHD who need medication like this to just plain make it through the day. But one of the conditions of a euvoluntary exchange is regret. For some of the marginal cases, what are they giving up? What are their alternatives?

If we assume that legislation like NCLB and culture like "you must go to college or else you're a failure at the game of life" are fixed (at least in the short run), the alternatives are ugly: disruptive kids ruin classroom environments for everyone, and creative classes like art and music (and recess) really do  have to be cut to make room for test prep. That's simply the uncomfortable truth of time management budgeting. Congress cannot bang a gavel and slow the earth in its orbit.

If we relax that assumption, perhaps consider re-evaluating the underlying purpose of education, and instead of treating it an international contest, our elected representatives might conclude that the federal (and state, and often local as well) efforts to boost measured success are misguided post hoc ergo propter hoc fallacies of affirming the consequent. If that happens, perhaps the once-ordinary daily exuberance can be remedied on the monkeybars, or banged out on a drum kit, or poured onto a canvas. Perhaps in the tumult of childhood, a kid might discover how to harness a wild mind rather than force it to conform. 

This is, as are many questions of public interest, a matter of moral intuition. The median constituent has no real incentive to think carefully about the implications of the complex institutions, of the ecology of something as large as the entire education system, let alone the philosophical underpinnings of it. The median constituent is far more likely to adopt a standard status quo bias and quibble over marginal adjustments. And so we fill our kids up with low-dose amphetamines, slap 'em on the rump and sit them down for their learnin'. 

I guess that's one way to prepare kids for the exciting future they'll face. Hm.


  1. I think you've misfired on this one, if I may. Your first link shows that for every two kids on medication, there is another kid with an ADHD diagnosis that is not on meds. That doesn't sound like a disease that is being diagnosed just to push pills. And there are clearly many kids who could use the medication but aren't on it. I've seen some schools do things like having unmedicated ADHD kids sit on medicine balls instead of chairs, to help keep them stimulated during class.

    Sure, there are kids who get meds who may not need them. Or, we can assume there are, I guess.

    It seems like you are just describing the unavoidable type I and II errors, and making assumptions of scale for "mood affiliation". Considering most essays I see take the same position as your post here, with little empirical backing, I suspect that the more prevalent error is for parents to avoid medication because of the stigma left by posts like this.

    Sorry. I generally like your stuff (when I can follow it), but I got to call you out on this one.

    1. It seemed like I was aiming at parents? Interesting. I intended to critique education institutions. Everyone in the "the majors" list can act perfectly rationally and still produce unintended consequences.

      I think you've got a good point though. A comparative institutional analysis might be a better approach. In some countries, medication is mandatory for an ADHD diagnosis, as in the kids will be taken into custody if the parent refuses treatment.


Do you have suggestions on where we could find more examples of this phenomenon?