Ritalin for School Children: The Teachers' Perspective

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RITALIN FOR SCHOOL CHILDREN: THE TEACHERS' PERSPECTIVE* STANLEY S. ROBIN, PH.D. Department of' Sociology, Western Michigan University JAMES J. Bosco. ED.D. Department of Teacher Education, Western Michigan University OBJECTIVES The use of psychotropic drugs has been controversial. One such drug is methylphenidate hydrocholoride (Ritalin). While there are sever- al other drugs used in the treatment of hyper- kinesis (chlorpromazine hydrochloride, dextro- amphetamine sulfate, diphenylhydantoin, etc.) Ritalin is for many physicians the drug of choice. With in the pages of popular and scholarly journals, as well as in the Committee Rooms of the United States House of Representatives, there is continuing discussion and debate of the appropriateness of the use of Ritalin for school children.'-5 During a time of great concern about the misuse of drugs and the expenditure of time and money to prevent andlor combat drug addiction, the use of Ritalin is not placidly accepted and has been the ob,ject of attack. One result of this debate has been an irregular but sometimes intense pressure upon school systems and individual teachers. The purpose of this study is to examine the attitudes and beliefs about Ritalin as well as teachers' conceptions of their role with regard to children who may be candidates for (or already taking) Ritalin. This drug is a commonly used treatment for hyperkinesis and is well known to teachers by its trade name. Therefore, it was chosen in this research as a class example of stimulants. Since the child who is being treated with Ritalin is frequently identified because of some learning abnormality, i t is obvious that the teacher may be involved in signaling the problem or providing information about the learning situation to the physician. The teacher may also be required to modify instructional patterns to be more compatible with the needs of the child. The teacher's attitudes about Ritalin may be expressed *This is a version of a paper presented at the American Educational Research Association meetings, February 1973, New Orleans, Louisiana. This research was supported by and conducted through the facilities of the Grand Rapids Public Schools-Western Michigan University Center for Educational Studies. Thanks are also given to Fredrick Margolis, M.D., for medical consultation, James Jones for research assistance, and Diane Krombeen for data management. in professional behavior which could affect the course of the medical treatment or reduce its usefulness in the school situation. Unsubstantiated by data, the charge has been made that teachers are promiscuous advocates of Ritalin use. I n this study, we addressed ourselves to these questions: ( 1 ) What information do teachers have about Ritalin'? (2) What attitude do teachers express toward Ritalin'? (3) What professional behaviors do teachers report when encountering a child with behavioral problems or one who is taking Ritalin'? We were also interested i n exploring relationships between attitudes and knowledge and other characteristics of teachers such as number of past experiences with children known by the teacher to be taking Ritalin. PROCEDURE The sub,jects for this study were 150 elementary school teachers (20 per cent sample) in the Grand Rapids Public Schools selected by systematic random sampling to participate in the study. A questionnaire developed for the study was called the Teacher's Opinion on Rittilin. The questionnaire consisted of three sections. Section One contained questions concerning the teachers' general views about education that bore upon their perception of the appropriateness of using Ritalin. Teachers' self-assessment of ability to recognize a hyperactive child and general medical philosophy were examined in this section. Section Two dealt specifically with Ritalin. The teachers' information about and attitudes toward Ri- talin were examined. Section Three concerned basic background questions about the teachers (age, grade level taught, etc.). FINDINGS The return rate for the questionnaire was 77 per cent. The sex and age distribution of the respondents were very similar to that of the population of teachers from which i t was drawn. Similarly, the distribution of the sample of teachers by number of years i n teaching did not differ from that in the school system." There is no reason to believe that our sample failed to 624 December 1973 Volume XLII l No. 10 TABLE I TABLE I1 TEACHERS' EXPERIENCE WITH AND KNOWLEDGE RELEVANT TO RITALIN (N = 114)* Item Frequency Per Cent Number of children taking Ritalin taught: 0 39 34.2 1 33 28.9 2 14 12.3 3 14 12.3 4 4 3.5 5 2 1.8 6+ 8 7.0 Has a member of your family taken (or now taking) Ritalin? Yes 3 2.6 No 109 95.6 No answer 2 1.8 Do you know what Ritalin is used for? Yes 97 85.1 No 14 12.3 No answer 3 2.6 Can you recognize an over-active child? Yes 108 95.6 No 5 4.4 *Responses on one questionnaire were incomplete; therefore, in some places N=113. represent the population of teachers in the school system. The large majority (85 per cent) reported they know what Ritalin is and for what i t is used (Table I). An even larger proportion (almost 95 per cent) reported they could recognize an over- active child. Two thirds of the teachers reported that they currently or previously had children in their classes whom they knew to be taking Ritalin. Slightly more than one half of these teachers had encountered more than one child (mostly two or three); the remainder reported one known child. The data indicated, therefore, that most teachers have some contact with the drug and that teachers believe they possess an understanding of the drug and the condition for which it is used. T h e f i rs t issue addres sed was: "What professional behaviors do teachers report when encountering a child with behavior problems or one who is taking Ritalin?" When asked what steps they take upon encountering an overactive child, the teachers' ma,jor efforts seemed to be within the school system (Table 11). A large ma.jority of the teachers specified that principals or school specialists are informed. A majority of IF YOU RECOGNIZE AN OVERACTIVE CHILD, WHAT STEPS DO YOU TAKE? (N=114) Categories Frequency Per Cent Nothing Inform family Inform principal Inform specialist Discuss with class Separate child Emphasize quiet activity Recommend contact doctor Total 1 81 87 95 16 12 30 46 368 - 1 .o 71.0 76.3 83.3 14.0 10.5 26.3 40.4 TABLE 111 FREQUENCY OF TEACHERS' EVALUATION ELICITED FOR CHILDREN ON RITALIN (N=75) Categories Frequency Per Cent* Almost always Generally Sometimes Not usually Almost never No response Total 21 28.0 16 21.3 13 17.3 6 8.0 13 17.3 - 6 8.0 75 100.0 *Tabulated for those teachers who report contact with children takinK Ritalin. the teachers also contact the parents. Forty per cent of the teachers suggest to parents that a physician be consulted. When a child is put on a Ritalin program (Table I I I ) , about two thirds of the teachers reported they are or have been asked to evaluate its effective- ness. Twenty-eight per cent reported that they have always been asked to evaluate and 39 per cent indicated that this occurs "generally" or "sometimes." Slightly over one third of the teachers made an evaluation contact with the physician. Ritalin usage in the schools, as previously noted, is not a rarity. Therefore, we asked the question: "How informed are teachers about the propert.ies of Ritalin'?" Table IV presents the responses of the teachers to posited characteristics of Ritalin. The teachers were asked to indicate whether they agreed, disagreed, or did not know if Ritalin has a series of specific properties. These findings should be viewed i n the context of the previously mentioned finding (Table I ) that 85 per cent of the teachers reported they know what Ritalin is used for. Noteworthy in this table is the The Journal of School Health 625 TABLE IV TEACHERS KNOWLEDGE OF PROPERTIES OF RITALIN* (N=ll4) Yes No Dont Know No Answer Property Frequency % Frequency % Frequency % Frequency % Is habit forming** 7 6.1 34 29.8 49 43.0 24 21.1 Has side effects? 37 32.5 I 6.1 46 40.4 24 21.1 Not needed after puberty? 16 14.0 11 9.1 61 53.5 26 22.8 Physiological action not understood? 43 31.7 9 7.9 36 31.6 26 22.8 Alters personalitya 22 19.3 44 38.6 24 21.1 24 21.1 Tranquilize& 81 71.1 6 5.3 2 1.8 25 21.9 Stimulates intelligencec 14 12.3 47 41.2 24 21.1 29 25.4 Must be taken in large doses** 4 3.5 54 47.4 31 21.2 25 21.9 Stimulates sexual behavior** 0 - 31 21.2 60 52.6 23 20.2 Attention span increasest 80 10.2 4 3.5 8 1.0 22 19.3 Impairs coordination* * 6 5.3 55 48.3 28 24.6 25 21.9 Effective for 5 hours a doset 23 20.2 I 6.1 5 1 50.0 21 23.1 Is toxic substancee 2 1.8 18 15.8 68 59.7 26 22.8 *These data were gathered primarily t o assess teachers felt state of knowledge about Ritalin. Only secondarily are we concerned with the accuracy of the teachers responses. The authors responses to these properties are indicated as the following: f True **False aThe drug can produce behavioral changes (See Eisenberg,= 1972, for a description of the effect of the drug on behavior). Whether this constitutes a personality change depends on the definition of personality. bRitalin is not classified pharmacologically as a tranquilizer. However, it can have a calming effect upon the behavior of children. d While the physiological action of the drugs are not directly comparable, our medical consultants agree that, on balance, this is probably the case. Less dangerous than aspirind 2 1.8 33 28.9 55 48.3 24 21.1 While the drug is not a smart pill, the modification of behavior which can result can lead to increased performance. toxicity ofRitalin in usually urescribed dosaae is minimal. proportion of dont know responses which ranged from 1.8 per cent to 60 per cent. Most items received 30 per cent to 40 per cent dont know responses. I n add i t ion , however, approximately 20 per cent to 25 per cent of the respondents failed to respond to each item. This large proportion of no responses is most reasonably interpreted as dont know. If the responses are interpreted as dont know, then 25 per cent to 75 per cent of the teachers responding did not know whether the specified properties of Ritalin were indeed present; the majority of the properties of Ritalin were responded to in the dont know and no answer categories by over 50 per cent of the sample. Substantive responses to these items, while frequently comprising less than 50 per cent of the responses, are of interest. Six per cent of the respondents, or 17 per cent of those responding substantively, thought Ritalin was habit-forming. Similarly, of those responding yes or no 14 per cent disagreed that it was not needed after puberty, 71 per cent agreed i t tranquilized, and 12 per cent thought it stimulated intelligence. These 626 substantive responses, in combination with the large proportion of dont know and no answers, lead to a questioning of the extent of understanding about Ritalin in this population of teachers. Finally, and of extreme importance to the assertions made in the debate about Ritalin, is the question: What attitudes do teachers express toward Ritalin and their role vis-u-vis the drug? Table V reports teachers feelings about their role in the use of Ritalin. One third of the teachers confined their involvement to being informed only. Slightly more than one third felt teachers should participate more actively by identifying students who may need Ritalin. The more extreme views of total involvement or total control were not endorsed by the teachers. It should be noted, also, that 16 per cent of the teachers did not respond to this item. Table VI deals directly with the teachers attitude toward the use of Ritalin for children under a physicians supervision. None of the teachers agreed with the most positive evaluation of Ritalin; less than 2 per cent selected the most negative. Most of the teachers who responded December 1973 Volume XLIII No. 10 TABLE V TEACHERS PERCEPTION OF THEIR ROLE IN USE OF RITALIN (N=114) TABLE VI TEACHERS FEELINGS ABOUT USE OF RITALIN IN=114) Agreement Role Frequency Per Cent Feeling Teacher should not be involved Teacher only informed Teacher help identify students Teacher should determine need Teacher should distribute Ritalin Others No answer Total in need 1 38 40 2 1 14 114 18 1 .o 33.3 35.1 1.8 1.0 12.3 15.8 100.0 Agreement Frequency Per Cent Use not justified 2 1.8 Is used too freely 13 11.4 Has limited use 4 1 41.2 Has resulted in fine gains 34 29.8 Resulted in new lives 0 No answer - 18 15.8 Total 114 100.0 - TABLE VII TEACHERS ATTITUDE TOWARD RITALIN BY FREQUENCY OF EVALUATION ELICITED FOR CHILDREN ON RITALIN* (N=116) Use Not Justified or Has Resulted in No Used Too Freely Limited Use Fine Gains Answer Frequency of Elicited Evaluation Frequency % Frequency % Frequency % Frequency % Almost always to sometimes 2 4.0 24 48.0 21 42.0 3 6.0 Not usually to almost never 6 28.6 8 38.1 4 19.1 3 14.3 No answer I 15.6 15 33.3 9 20.0 14 31.1 *x2=33.39; p that with increased exposure to children taking Ritalin and with more positive attitudes toward Ritalin there was no consistent o r systematic decrease in the proportion of dont know o r proportion of the correct attribution of properties to Ritalin. Put another way, experience with Ritalin and endorsement of its use are not associated with knowledge about the drug. CONCLUSIONS AND IMPLICATIONS Overall, the attitudes of teachers toward the use of Ritalin are cautiously favorable. These seems to be no strong opposition to Ritalin from practicing teachers. While it is not uncommon for a teacher to have direct experience with a pupil on a Ritalin regime, it is uncommon for teachers to have specific and accurate information about the characteristics of the drug. Further, knowledge of he drug does not increase with an increase in experience o r an increase in favorable attitude toward the drug. Since the use of Ritalin is so closely connected with the classroom performance of the child, the necessity for the teacher to understand it is clear. The educationally salient properties of Ritalin can be explained through the normal use of in-ser- vice training. School systems might use published materials to acquaint teachers with the properties and uses of Ritalin. Colleges of education should make instruction about behavior modification drugs such as Ritalin a routine part of their curriculum. A clear distinction between indoctrination and information needs t o be made. Physicians prescribe Ritalin and teachers d o have children on Ritalin in their classrooms. Recommending that teachers be as knowledgeable as possible is not an endorsement of Ritalin. I t seems clear that the welfare of the child who is taking o r who is a candidate for Ritalin requires closer coordination of the medical and teaching profession, Although the l i terature recommends close interaction between teacher and physician, such interaction is not usual. Forty per cent of the teachers reported that they recommend consul ta t ion with a physician for children who appear hyperactive; only 15 per cent of the teachers, however. reported that physicians request evaluation from them concern ing ch i ldren who have been prescr ibed Ri ta l in . D i rec t communica t ion between physician and teacher is infrequent. Teachers should be encouraged to work in cooperation with physicians and the physicians should make greater use of the teacher, since teachers can perform a unique function in the evaluation of the success of the treatment.? Teachers are equally divided between a passive role, an active and cooperative role, and m i s c e l l a n e o u s a n d u n c e r t a i n r e s p o n s e s . Considering the disparate beliefs and professional behaviors of teachers, the question could be posed: Is individual decision-making on the part of the teacher adequate for the welfare of children who a r e o r will be taking R i t a l in? T h e uncertainties of the teachers underline the complexities of the problem. Superintendents are faced with political pressures, teachers are divided with regard to their professional role, physicians will continue to prescribe Ritalin and similar drugs, and society will both endorse and condemn the use of Ritalin for children. This calls for no less than a school system-wide involvement in the formation of coherent educational perspec- tives in the use of Ritalin and other behavior modification drugs. 1. 2. 3. 4. 5 . 6. 7. 8. REFERENCES Charles A F Drugs for hyperactive children: the case of Ritalin. The New Republic (Oct 23) 1971, Vinnedge H: Politicians who would practice medicine: drugs for children. The New Republic (Mar 13) 1971, pp 13-15. Witter C: Drugging and schooling. Transaction Ladd ET: Pills for classroom peace. Saturday Review 53:66-68 (Nov 21) 1970. Schmitt BD: Responsibility for school problems: an objection to pediatric globalism. Pediatrics 44:771- 773 (Nov) 1969. Jones JD (ed): Profile of the Grand Rapids Schools. Western Michigan University Center for Educational Studies, Grand Rapids Public Schools, 1971. Oettinger L Jr: Learning disorders and the use of drugs in children. Rehabilitation Literature 32:162-167, 170 (Jun) 1971. Eisenberg L: The clinical use of stimulant drugs in children. Pediatrics 49:709-715 (May) 1972. pp 17-19. 8~30-34 (JUVAUg) 1971. BIBLIOGRAPHY Knobel M: Psychopharmacology for the hyperkinetic child. Arch Gen Psych 6:1.98-202 (Jan-Jun) 1962. Debate on drugging for classroom control. Nations Schools 39:88 (Jul) 1971. Report of the Conference on the Use of Stimulant Drugs in the Treatment of Behaviorally Disturbed Young School Children. Washington: Office of Child Development and the Office of the Assistant Secretary for Health and Scientific Affairs, USDHEW, Jan 1971. ?Some clinical observation indicates that the hyperkinetic child is often misleadingly quiescent in a one-to-one medical interaction with a physician? 628 December 1973 Volume XLIII No. I0

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