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The Doctor's Corner

Dr. David Harley B.A.,M.A.,M.A.,Ph.D.

Dr. Harley completed a Master’s degree in Philosophy specializing in analytical philosophy and philosophy of mind as well as a Master’s degree in History specializing in early 20th century intellectual history.  He completed a Ph.D. degree in Education at the University of Toronto specializing in educational theory in general and the educational theory and practice of the noted British philosopher Bertrand Russell in specific.  His thesis research employed the assistance of Bertrand Russell’s daughter to track down ex-teachers and ex-students from his experimental school Beacon Hill.  He was awarded a Canada Council Doctoral Award as well as a Canada Council Post Doctoral Award.  He has over 30 years of direct experience as an educational consultant, principal, school administrator and researcher.

The purpose of his blog is to present various opinions, articles and book reviews related to the current state of education and the changing challenges presented to students, teachers and parents. 

BOOK REVIEW: ADHD Nation: Children, Doctors, Big Pharma, and the Making of an American Epidemic. Alan Schwarz

ADHD Nation is one of the latest of many books devoted to the topic of ADHD.  It is unique in that it brings into the discussion the current views of Dr. Conners (an early pioneer in the area) while at the same time introducing the reader to some interesting and informative facts.   

While stating that ADHD is real and exists and must be taken very seriously Schwarz puts aside the question as to whether or not it exists, states categorically that it does and then moves on to the issues of overdiagnosis and the rampant abuse of stimulant medications - or as he puts it “The Making of an American Epidemic”.   At first blush, this appears to be a safer argument to embark upon.  However, implicit in the information and arguments that he presents appear the very reasons why many question the legitimacy of the entire enterprise; any account of the rise and discovery of ADHD cannot be made without giving full credit to the pharmaceutical companies' role in the simultaneous promotion of an affliction together with its proposed cures. The underwriting, promotion and relaxing of the symptoms necessary to qualify for diagnosis are inexorably interwoven with the promotion of medications and the driving force behind the enterprise is unabashedly that of profit.  What Swartz clearly identifies is that with the billions of dollars now involved in the identification, therapies and medications of ADHD, few who are involved can free themselves from some degree of complicity in what has become a profitable industry.  As such, one is led to conclude that money and self- interest are compelling engines driving the phenomenon independently of genuine concern for the afflicted.

Interestingly enough, even the term ‘ADHD’ required some packaging. Early attempts to describe the general condition included  ‘Hyperkinetic Impulse Disorder’ and ‘Minimal Brain Damage’ among others.  Attention Deficit emerged as a satisfactory and acceptable description in terms of its messaging by striking a balance between what might be incomprehensible verbiage or an embarrassing personal flaw.  ‘Attention’ was after all a term that everyone knew and having difficulty paying attention was something that everyone experienced to some degree.   In a similar manner, the medications themselves needed names that would not ring alarms.  And so Ritalin was named by a research chemist after his girlfriend named Rita who benefited from the medication both by encouraging her weight loss and invigorating her tennis game. Other medications provided similar soothing or non-threatening names.  Having packaged the product both in terms of the problem and the cure, the next step was to identify the market.  However, unlike the common cold, the diagnostic process itself needed to be tailored and also marketed.

Schwarz maintains that according to the American Psychiatric Association’s determination, the condition of ADHD affects about 5% of children and most of this number are male.  However, Schwartz states that the current U.S. nationwide rate is 20% with some states topping 30% and some counties approaching 50%.  Early pioneers in ADHD research and development believed that no more than 3-5 % of the population would be affected.  Dr. Conners, who became famous and personally quite rich through his introduction of the Conner’s diagnostic test, very widely used for the diagnosis of ADHD, was distraught when interviewed for the book. Having originally been sure that no more than 3-5 % of children would be afflicted, the current inflated numbers could only be accounted for by virtue of misdiagnosis.  Thus Schwarz concludes that given this huge gap ADHD has become the most misdiagnosed condition in American medicine.  Therefore, the thesis promoted by this book is that the numbers can be rolled back by making the conditions for diagnosis stricter.  However, it would seem that Schwartz’s solution amounts to no more than bell curving undergraduate exam marks to ensure that 5% of the class fails.    In short, the admission that the definition and setting of the necessary and sufficient conditions of being diagnosed with ADHD are directly responsible for determining the number of people who can be legitimately identified as such infers that the diagnosis is determined by the definition.  The fact that Conners believed that the condition could only afflict a limited range of no more than 5% of the population is a belief and could not qualify as a scientific observation since there would be no way of knowing this before the fact.  How could one know therefore that no more than 5% of the population was afflicted? Perhaps the statement is more of the form that no more than 5% of the population ‘should’ be afflicted.  The argument that the sufficient and necessary conditions should be made more restrictive in order to reduce the percentage that would qualify for a diagnosis to a preconceived range infers an arbitrary character to the entire enterprise.

What therefore becomes apparent is that whatever current test is used to determine ADHD, all reduce ultimately to subjectivity as it is only a thing insofar as it is defined as being such.  As the sufficient and necessary condition is made more or less restrictive, more or less instances of the thing come or go out of existence. No growth, virus, bacteria or physical dysfunction can be identified with it. Despite attempts to argue that some physiological characteristics can be identified with ADHD through brain scans and computer colour enhancements, no credibility has been provided for this by the American Medical Association.  Instead, a cluster of diverse behaviours is made unique not by their existence but by their subjectively determined degree and effect on normal functioning.  Indeed, all of these behaviours can be ignored if there is no effect upon normal functioning and so there is an ad hoc character to the causal relationship insofar that the assumption exists that these behaviours could all exist to the same degree and either affect or not affect normal behavior.  In short, the behaviours associated with determining the existence of ADHD are necessary characteristics only after it is determined that there is a dysfunction within a specific environment.  In a real sense, the dysfunction comes first and the explanation follows later.

Looking at the actual diagnostic tools is a help to bring the discussion down from the abstract to the concrete.  For example one of the first commercially marketed rating scales developed by Dr. Conners described 28 behaviours:

  1. Restless in the “squirmy” sense
  2. Makes inappropriate noises when he/she shouldn’t
  3. Demands must be met immediately
  4. Acts “smart” (impudent or sassy)
  5. Temper outbursts and unpredictable behaviour       
  6. Overly sensitive to criticism
  7. Distractibility or attention span a problem
  8. Disturbs other children
  9. Daydreams
  10. Pouts and sulks
  11. Mood changes quickly and drastically
  12. Quarrelsome
  13. Submissive attitude towards authority
  14. Restless, always up and on the go
  15. Excitable, impulsive
  16. Excessive demands for teacher’s attention
  17. Appears to be unaccepted by group
  18. Appears to be easily led by other children
  19. No sense of fair play
  20. Appears to lack leadership
  21. Fails to finish things that he/she starts
  22. Childish and immature
  23. Denies mistakes or blames others
  24. Does not get along with other children
  25. Uncooperative with classmates
  26. Easily frustrated in efforts
  27. Uncooperative with teacher
  28. Difficulty in learning

Each of these behaviours is then rated 0 through 3 with 0 signifying never, 1 just a little, 2 pretty much and 3 very much.  The score would then be tabulated with a minimum score being selected to qualify as borderline ADHD and so on.

As of 1980 and the publication of the DSM or Diagnostic and Statistical Manual, Attention Deficit Disorder details as to how doctor’s should diagnosis the syndrome were provided as follows:

Inattention.  At least three of the following:

  1. often fails to finish things he or she starts
  2. often doesn’t seem to listen
  3. easily distracted
  4. has difficulty concentrating on schoolwork or other tasks requiring sustained attention
  5. has difficulty sticking to a play activity

B. Impulsivity.  At least three of the following:

  1. often acts before thinking
  2.  shifts excessively from one activity to another
  3. has difficulty organizing work(this is not due to cognitive impairment)
  4. needs a lot of supervision
  5. frequently calls out in class
  6. has difficulty awaiting a turn in games or group situations

C.  Hyperactivity.  At least two of the following:

  1.  runs about or climbs on things excessively
  2. has difficulty sitting still or fidgets excessively
  3. has difficulty staying seated
  4. moves about excessively during sleep
  5. is always “on the go” or acts as if “driven by a motor”

Each edition of the DSM has relaxed the sufficient and necessary conditions so as to increase exponentially the number of people who could qualify to be diagnosed.  As the DSM is not the only basis for diagnosis and professional interpretations as to what does and does not qualify someone to be diagnosed with ADHD further complicates the issue.  However, the fact that relaxing a definition or changing it can either increase or decrease a condition can lead to speculation as to whether or not the definition chases the condition or the condition chases the definition.

Ultimately, however, it would also seem that who and what qualifies may be less important than the issue of the millions who apparently benefit from the variety of medications now prescribed.  This brings up the issue of performance enhancing drugs in general. Schwarz mentions that during WWII Winston Churchill approved the production of 72 million Benzedrine tablets for distribution to troops to improve performance.  Widespread use and abuse of Benzedrine followed the war with people commonly taking it in the morning with coffee and with the Rolling Stones referring to it in song as “Mother’s Little Helper”.  Available without a prescription and over the counter, there were no curbs to consumption.  As an energizer and as a weight loss pill, it gained popularity to the point where it was recognized as a threat to public health and placed on a restricted substance list.  Another stimulant medication called Dexadrine was marketed as a substitute for the by then maligned Benzedrine.  However, by early 1970, some 4 billion Dexedrine tablets were being dispensed in the U.S. each year and some 7% of all Vietnam forces became abusers or addicts.

It becomes apparent therefore that a steady market for stimulant medications existed prior to the advent of ADHD or other learning challenges. Whereas there is no doubt that such medications enhance performance, the fact that they address symptoms in this process does not logically infer the existence of an ailment that they are supposed to address.  It remains to discuss ADHD medications, not as one would discuss an antibiotic that fights an infection and would have no beneficial effects unless you were sick as opposed to stimulant medications that enhance performance generally. 

To take the argument one step further, if stimulant medications increase most people's ability to focus and stay on task why not allow anyone to use them? This is a question that has been taken up at universities and colleges across the USA and Canada where thousands of students are accessing these performance-enhancing drugs to assist them in studying and writing exams.  In these contexts, the medications are valued because of their ability to enhance abilities in students whose abilities were strong enough to get them into top universities and competitive programmes.  In short, there is no argument that medications to address ADHD issues are effective in many cases.  It is equally true that these medications have similar effects in enhancing performance even where there is no dysfunction.  It could be therefore argued that in the athletic realm we should issue medications to athletes whose performance is substandard but not allow them to better athletes as a means of levelling the playing field.

It has always been recognized that school is not an environment suited to everyone and traditionally a number of students left school and entered the trades or the workforce.  It is also the case that school was viewed as a privilege rather than an affliction and was therefore valued.  As school has become an imposed obligation upon youth by the state, the academic component has strayed further away from learning along traditional lines to a form of socialization and enculturation designed to ensure that its products share common values, ideas and attitudes.  Despite universal claims from educators that government funded schools do a better job than ever, there is no empirical evidence to prove the claim that modern schools have advanced beyond the successes of the one-room schoolhouse. They are certainly more complex, expensive and inclusive.  Much of this misdirection is as a result of being all things to all people.  Failure at school is not a failure at life and those who are not suited by nature, temperament or timing to be successful in that particular environment may have many strengths in other directions that are better being capitalized upon than suppressed.

Part of the problems with much of current education is that students feel that they are being forced to attend and that what they are being taught has no value or interest to them.  It is interesting that in the third world education is regarded by most students as a privilege and a way to advance themselves whereas in the West many young people regard education as an affliction developed by adults to destroy their adolescence.  Just as all people are not destined to be athletes, it is equally true that not all people are destined to be scholars.  It would seem then that in keeping with principles of consistency that athletics should be considered for medications as well in order that poor performers might perform better.   However, it might be also argued in both academic and athletic environments that if any portion is receiving artificial assistance to enhance performance then perhaps everyone should enjoy the same benefit.

In conclusion, ADHD Nation is a book worth reading in terms of the new information and updates taking place as part of the crisis of overdiagnosis. It is however also of value insofar as it provokes discussion around the central issues concerning the birth and evolution of the ADHD phenomenon.

Fairness in University Applications Under Debate

An article was recently posted by Global News entitled “One university’s secret list to judge applicants by their high schools - not just their marks” 

The article discusses the use by the University of Waterloo of computerized studies in which the final high school marks by which students were admitted to the university are compared to the final university averages achieved by those students.  The results are organized by specific high schools from which the students originated. These have sometimes been referred to as drop rate studies.  The idea is that if you have a large enough sample from a school that this will give some information of value.  These studies have been rumoured to be carried on for years and they first came to my attention 30 years ago and arose from concerns arising from the different standards and values of marks given by individual schools and teachers.  

At one time in Ontario, all students graduating from high schools in grade 13 were required to write standardized provincial examinations. The exams were set by people in the Ministry of Education and were sent to schools for students to write under strict supervision.  The completed exams were then sent to the Ministry to be marked by people who had no knowledge of who had written them.  The purpose was to ensure that there was no favouritism involved in the marking and that the same test was written by everyone.  This standardization was to ensure fairness and impartiality.  It was a system almost universally believed to be the standard of how to ensure the integrity of the system.  After the Hall Dennis report came into effect in the late 1960’s and Ontario abandoned the provincial exams, what the critics had expected happened and gradually the ability of teachers to set their own exams and mark their own papers began to give rise to variations in what those marks meant in terms of any gold standard.  The issue of fairness became particularly pressing given the value of marks or even portions of marks in terms of university admission and scholarships. It became obvious that some students were denied or granted admission to a program or scholarships merely because they attended the wrong school or were taught by the wrong teacher.  The inherent unfairness of this was apparent to university admissions departments and movements began to emerge proposing standardized entrance examinations for all Ontario universities.  My understanding is that such a proposal was put forth to then Premier David Peterson.  However, having standardized entrance tests administered at the same time that students were still attending high school would have created a potentially embarrassing situation by proving that significant variations existed and provide fuel for critics of the educational system and the government. These drop rate studies were often dismissed on the grounds that so many factors weighed into possible explanations as to why marks dropped including being away from home and coping with increased levels of individual freedom.  Testing while students were still attending high school would have removed these mitigating factors and arguably laid bare the problem in a way that could not be contested.   

The current article revolves around the story of Global News requesting in 2016 information from the University of Waterloo regarding the drop rate statistics or adjustment factor for students entering their engineering programme.   When the university refused to comply with the request, Global appealed to Ontario’s information and privacy commissioner resulting in a ruling to release the information in June of 2018.  According to the information released, the average drop in a student’s average in the engineering programme was 16 % coming from an average Ontario High School. However, some high schools had an average drop of over 27%.  The statistics released were for 2016 through 2018 admission cycles and the article publishes a long list of public, separate and private schools as well as their respective drop rates.   I would urge anyone interested in this to access the original article online. 

However, the article also indicates the problems associated not only with the varying standards of different schools and teachers but also different provinces and countries.  Students from New Brunswick, for example, had their marks drop on average by over 26 per cent as opposed to graduates of Quebec’s CEGEP stream who averaged a drop of only 5.2 per cent.  In terms of international students, the worst offenders came from Egypt, Saudi Arabia and Bangladesh.  Countries with the least drop in their marks were Indonesia, Singapore and Malaysia.

Historically, Ontario had two high school graduations. The first diploma was issued for grade 12 after which students either entered the workforce, attended community colleges or continued on to grade 13.  Grade 13 graduates received another diploma that allowed them to continue on to university.  The purpose of Grade 13 was specifically to prepare students for university and so course content and delivery was aligned to that purpose.  When grade 13 was eliminated we ended up with a system where graduation could be completed in 4 years, 4 ½ years or 5 years.  The total number of credits required was 30 instead of 33 and grade 13 credits were replaced with OACs or Ontario Academic Credits. As part of the reforms introduced, university professors were consulted in the preparation of these credits to attempt a seamless transition to university first-year subjects.  OACs were later eliminated as the system gravitated more towards an emphasis upon graduating from high school and less on high school as a preliminary for higher education.  As one ministry representative said to an audience of principals at an information seminar that I attended, “high schools are no longer and never should have been clearing houses for universities”.

The latest reforms in education have concentrated on the notion of student success while at the same time downplaying the competitive aspect of education as well as the notion of the educational process as part of a meritocracy.  It would appear that in practice the emphasis upon success has also implied the removal of failure and success seems to be defined in terms of either achieving a credit or obtaining a high school graduation diploma. Much of these initiatives have run counter to university culture which is highly competitive for admission but also within programmes for either completion of degrees or the ability to proceed onward to graduate school.

It is important here to stress the importance of meritocracy within the educational process.  In earlier times and in many other countries, access to higher education was severely restricted upon socio-economic grounds and access to preferred professions was and is comparatively easy provided the family had the means.  I read recently of the story of Banting (the inventor of insulin) who after entering the University of Toronto and failing his business programme decided to change to medicine in his next attempt with apparently very positive results.  This would obviously be impossible presently.  The concept of a meritocracy was founded upon the idea that opportunities should be accessed on the basis of merit rather than money and influence.  This would have the advantage of providing opportunities on the basis of pure merit and ability and would also be in keeping with a democratic concept of equal access.  In a sense then, the idea of a meritocracy was very much like a free market system in which individuals competed for desirable opportunities and jobs using merit as currency.  This is implicit in the current university application procedures where admissions standards fluctuate from year to year based upon the number and quality of applicants. The same principle is inherently present within high schools in that how students graduate determines post-secondary options going forward.  The elimination of a focus on academic competition is an essential aspect of the success movement since comparisons of relative levels of achievement as largely focused upon being relative to the individual as opposed to the achievement of others or to a uniform consistent standard.  So successful has this policy been that I have frequently encountered students over the past few years who were taken aback at the fact that they actually had to compete to get into university.  Many have had the impression that if they wanted to go and their parent was prepared to pay that they could go to any university or programme.

It is fairly clear that the alternatives to a meritocracy based upon competition are few and far between and range from conducting lotteries for admission to simply allowing applicants to bid financially for programmes.

At any rate, it is a worthwhile discussion to explore these issues and to consider carefully ‘fairness’ in the existing application process.