I recently learned that many professional graduate schools – law schools, business schools, even medical schools – continue to provide “test accommodations” to students with attention deficit hyperactivity disorder, or ADHD. These accommodations usually take the form of extra time on the exam, when time is a crucial resource.
Of course, it’s not just grad schools who are struggling with the question of how to treat students with ADHD. Princeton is currently embroiled in a lawsuit:
A learning-disabled freshman suing Princeton University for refusing to allow her extra time to take exams was dealt a setback this week, as a federal judge refused a temporary restraining order on the eve of midterms. But plaintiff Diane Metcalf-Leggette still has a shot at getting a preliminary injunction in January, when final exams begin, if she can show probability of success in her suit under the Americans with Disabilities Act.
For now, I’d like to bracket questions about the overdiagnosis and overtreatment of ADHD. Instead, I’m interested in thinking about the treatment of developmental disorders, like ADHD, once “development” is over and the adult brain is fully formed. The most authoritative study on the question of brain development and ADHD was led by researchers at the NIH, NIMH and McGill, and published in 2007 in PNAS. The scientists scanned the brains of 223 children with ADHD and 223 control subjects, from a variety of different age groups. They analyzed these anatomical snapshots for “cortical thickness,” which served as a proxy for brain development.
They found that ADHD is largely a developmental problem: the brains of kids with ADHD develop at a significantly slower pace than normal. For instance, the median age by which 50 percent of the cortical points attained peak thickness for the ADHD group was 10.5 years, while the median age for the control group was 7.5 years. This lag was most obvious in the lateral parts of the prefrontal cortex, which is a brain area essential for most of the executive functions that appear to compromised in children with ADHD. (On average, their frontal lobes were three and a half years behind schedule. The only region in which ADHD children were ahead of the controls in their maturational peak was the motor cortex, which might explain the hyperactivity part of the disorder.) The good news, however, is that the ADHD brain almost always recovers from its slow start. By the end of adolescence, the frontal lobes in kids with ADHD have reached normal size. It’s not a coincidence that the behavioral problems typically begin to disappear at about the same time. These children are finally able to counter their urges and compulsions. They get better at directing their attention and shutting out distractions. The world is no longer such an overwhelming place.
Should this science change our response to ADHD at the university level? After all, if the majority of children with the disorder are no longer suffering from a developmental lag, then how do we justify extended time and other academic accommodations? (Some children, of course, might still be suffering from an thin prefrontal cortex; not everyone catches up.) Do we then administer brain scans to students, to check on their anatomy? Or do we continue to rely on a probably obsolete diagnosis, made years earlier?
The larger question has to do with the interface of neuroscience and society. There is something powerful about being able to take an amorphous syndrome like ADHD and make it real, by referencing actual brain differences in actual subjects. But if we’re going to take this empiricism seriously, and use it to justify medical treatment at a young age, then it seems like we also have to take the flip-side seriously as well. Some development disorders, after all, are like adolescence: we eventually grow out of them. The brain catches up.
And then there’s the larger question of medicalizing every observed “difference”. As we peer into our black box with increasing clarity, we’ll come to see that those three pounds of gelatinous meat hide enormous individual variation. It won’t be easy figuring out which variations require accommodations and special treatment, but that’s a conversation we’re going to need to have.