Active or Hyperactive?

A controversy has raged with increased intensity in recent times relating to the use of medication in young – even preschool age children – to address behavioral issues.  A most thoughtful contribution to this discussion appeared last week in a N. Y. Times’ article titled “Raising the Ritalin Generation.”

In it author, Bronwen Hruska, describes the progression from her son’s third grade teacher’s suggestion that medication might help him “settle down”, to evaluations and then prescriptions for Ritalin.  As is often the case when Ritalin or similar drugs are prescribed, it was not to be taken at home, on weekends or during vacations. Essentially, it was being prescribed and taken for school attendance.

The article offers statistics indicating that as of 2010, 5.2 million children between the ages of 3 and 17 had been given diagnoses of attention deficit hyperactivity disorder.  Statistics also show an increase in the frequency of this diagnosis in the last decade, one clearly  reflected in the frequency with which this question is raised both by teachers and by parents.  Questions about hyperactivity and/or attention focusing come quickly to mind when a parent or teacher is concerned about a child’s behavior.

How is this to be explained?  Has there really been an increase in these disorders?  Are we simply better able to make the diagnosis now than in years past, or are there other factors leading to an increase in the diagnosis being made?  Actually, in large measure this diagnosis is made based on the perceptions and reports of parents and teachers.  Although psychiatric and psychological examinations are also part of the process, often children whose behavior seems to be of concern in group situations, like school, do very well in one-on-one visits with an examiner.

In fact, there is a large subjective element in this diagnosis.  When does active become hyperactive?  When does a high activity level, or restlessness, become an attention deficit?  What is the tolerance level of a particular parent or teacher?  What are the expectations for behavior of the children about whom there is concern?

In thinking about these questions it is important to acknowledge that there are children who are clearly having a hard time managing their bodies or their behavior and do not seem able to meet age appropriate expectations.  Often, it is not only the adults around them who are distressed by this but the children themselves.  Whether the use of medications is indicated in such situations is another question to be best answered with medical consultation.  The use of medication even in such children is controversial in itself.

Unfortunately, numerous factors have blurred the answer to the questions  raised above.  One factor certainly, is the pressure on teachers to meet designated requirements in their classrooms for achievement standards that ultimately relate to funding for schools and often to their own personal advancement as well.  Large classes make individual attention difficult and this leads to a greater demand for compliance and conformity.

Another important factor is that in recent years children attend groups at younger and younger ages.  In my experience, once children are in a group – no matter how young they are – there is a tendency for adults to think of them as being in school.  Judgments are often made of their behavior in relation to expectations that exist for appropriate school behavior.  But functioning in a group requires skills that young children have not yet developed or are still developing, like impulse control, frustration tolerance, separating from caregivers, turn-taking, and most of all acquiring language with which to express needs and feelings.

The development of these skills is a process that takes place over time and proceeds at a different pace for different children.  As a consequence, not all children of the same chronological age are at the same place in their development.  In addition, the development of different skills is variable within each individual child, so that a child who is ahead of his peers in one area may seem behind in another.  Unfortunately, this fact of a developmental range within any group of children has been lost.  Increasingly, adult expectations for behavior are based on a misleading standard of norms. 

Particularly when it comes to activity level there is great variation in young children.  Motor activity plays an important role in the early years as children gain increasing mastery of their bodies and of their environment.  Sitting at attention in a circle or at a table or desk can be very challenging for some children.  As they go forward in school, this may become a significant factor in their readiness to attend in the manner a teacher may require or wish for. It is here that a teacher’s ability to allow for such variation plays an important role.  Increasingly, it would seem, such allowances are too often not made.

In her article, Ms. Hurska, whose son is now a successful high school sophomore, suggests that we now have a new “normal” which rejects the idea of average.  “Exceptional and extraordinary . . . are what many schools expect from a typical student.”  Given the competitive nature of school admissions, it also has become what many parents expect.  What this has meant is that too often children who don’t meet this new definition are thought to have a problem.  Yet in many cases it is the expectation that is off the mark, rather than the child.  

If a child seems to be having difficulty, parents need to think about what is being required of him or her, and what they know about their own child.  There are various ways to understand and to help children over developmental bumps without labeling them  “disorders.”

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