When it pays for something to be wrong with the kid, you’re often going to find something wrong with the kid.

An interesting story from the Boston Globe:

Geneva Fielding, a single mother since age 16, has struggled to raise her three energetic boys in the housing projects of Roxbury. Nothing has come easily, least of all money.

Even so, she resisted some years back when neighbors told her about a federal program called SSI that could pay her thousands of dollars a year. The benefit was a lot like welfare, better in many ways, but it came with a catch: To qualify, a child had to be disabled. And if the disability was mental or behavioral — something like ADHD — the child pretty much had to be taking psychotropic drugs.

Fielding never liked the sound of that. She had long believed too many children take such medications, and she avoided them, even as clinicians were putting names to her boys’ troubles: oppositional defiant disorder, depression, ADHD. But then, as bills mounted, friends nudged her about SSI: “Go try.’’

Eventually she did, putting in applications for her two older sons. Neither was on medications; both were rejected. Then last year, school officials persuaded her to let her 10-year-old try a drug for his impulsiveness. Within weeks, his SSI application was approved.

“To get the check,’’ Fielding, 34, has concluded with regret, “you’ve got to medicate the child.’’

There is nothing illegal about what Fielding did — and a lot that is perhaps understandable for a mother in her plight. But her worries and her experience capture, in one case, how this little-scrutinized $10 billion federal disability program has gone seriously astray, becoming an alternative welfare system with troubling built-in incentives that risk harm to children.

I suppose it’s only a sense of ethics that would prevent Fielding from simply throwing the drugs away (and the law from selling them). It’s an interesting dilemma. I don’t have any problem helping out parents with kids that have disabilities. My ex-sorta Delsie ended up marrying a man with a disabled (like, seriously disabled) daughter and even though she’s very positive and upbeat it sounds like a real handful. And really expensive.

Of course, when you implement these programs you always have to be on the lookout for perverse incentives. Whether Fielding is genuinely doing wrong or not is unsure. That’s part of the problem when it comes to issues like ADHD, depression, and other things. With Down Syndrome, it’s an up-or-down thing. A kid with serious autism pretty obviously has something abnormal about them. But a lot of psychological issues are difficult to nail down. There’s no good blood-test and brainscans and the like are expensive and as much a product of learning about disorder (through subjective diagnosis) than objective diagnosis. This has (unfortunately) lead some to believe that the entire disorder (ADHD in this case) is really a “disorder” or simply a product of or metaphor for our times. Or that it’s simply a matter of laziness.

Daniel Carlat is a doctor frustrated with parents coming to him for the reasons cited in the Globe article:

As a psychiatrist besieged by patients asking me to diagnose them with ADHD so that they can get a prescription for Ritalin, I both agree and disagree with Dr. Klass. Yes, there are clearly some patients at the extreme end of the severity spectrum whose brains simply won’t allow them to focus. These are the patients who end up being enrolled in all the “convincing” neurobiology studies outlined by Klass — the studies that suggest that ADHD might involve frontal lobe problems and dopamine deficiencies. But for every child or adult with obvious ADHD, I suspect there are several who have a “soft” or even, yes, a “mythical” version of the disorder.

The prototypical mythical case is the parent of an ADHD child who comes into my office saying that he or she tried their child’s Ritalin and found that suddenly they were incredibly productive at work. “I think I must have ADHD, doc.”

I then have to explain that Ritalin is a version of that old college term-paper completion engine — speed — and that studies show that just about anybody who takes an ADHD drug thinks more quickly and focuses more acutely. That doesn’t mean you have ADHD.

But what does? The inability to really answer that question is as much the problem as SSI, video games, medication nation, and a host of other things. That doesn’t, as Carlat notes, make it entirely mythical. But the ambiguity of it all is pretty problematic. It can be an attractive excuse for failure for some. If your kid having ADHD or not having ADHD is the difference between a few hundred dollars a month and better medical care, it’s not difficult for even honest and well-intentioned parent to determine that their kids probably have it. The ambiguity around diagnosis may make it hard for a psychiatrist to argue otherwise (and they can always find another psychiatrist if they do). It’s really not surprising that people would respond to these incentives. Some are dishonest, some are conflicted like Fielding, but a lot will simply believe what it is advantageous to believe.


Category: Hospital, Statehouse

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41 Responses to Incentivized Disorder

  1. Sheila Tone says:

    I think whatever improves my kid’s performance should be done, especially if he’s below average. The state special ed standard to receive services (not talking about cash payments, just special services) is one and a half standard deviations before the norm in even one of several subcategories. So my babytalking 4-year-old (“No touch my Shard! No, he no like being held! No by you!”) qualifies for some free speech therapy from the public school district.

    I think poor kids should get the same scrutiny that upper-middle-class kids get as far as remedial services. Poor kids, especially foster kids, seem to get the most scrutiny for defects and problems because of the funding that can come with it. In foster care, it’s called “D-rate,” and I’m often surprised at who qualifies for it.

  2. Sheila Tone says:

    Just so we’re clear, I had to actively pursue these services for my son, he didn’t get funneled into them. If I didn’t have teachers in the family advising me how to navigate the system, I may not have gone this route.

    I don’t know about the part where she says “you have to take the meds,” though. I’ve got a lot of adult clients who get SSI checks for mental disabilities, especiall “bipolar,” and aren’t required to receive any therapy or meds. Once they get the diagnosis they’re set with a monthly check indefinitely. And often smoking “medical marijuana” to boot.

  3. Kirk says:

    I think the headline of your post pretty much fits the below NYT article on mental health in colleges. After reading part of the article, and looking at the picture of the earnest young doctor involved, I can only get the feeling that she’s running around at full speed trying to treat students the moment they start having problems–God forbid she wait fifteen minutes for them to sort out the problems on their own.

    I mean really, do people need a doctor’s help to deal with depression caused by cramming for finals? Are term papers so terrifying that students facing them constitute a serious suicide risk? Really?

    http://www.nytimes.com/2010/12/20/health/20campus.html?src=me&ref=health

  4. trumwill says:

    My elementary school tried to put me in remedial-ed because I was “slow”. When I graduated from college, mom wanted to send the counseler a copy of my college degree.

  5. Sheila Tone says:

    “My elementary school tried to put me in remedial-ed because I was “slow”.”

    I’ve got you beat on that one. My first-grade teacher thought I was autistic! Despite my topping out the charts on the standardized tests. Turns out I was looking out the window too much because I was bored.

    I can see today why someone might think I was a spectrum-type, though.

  6. Sheila Tone says:

    A lot of people seem to think it’s cheating or dishonest to do things to enhance one’s performance. I think if something can make a person more effective, they should do or take that thing, unless there are harmful side effects.

    Some people seem to have the idea that unless a kid is, what, catatonic or droolingly incoherent, it’s somehow UNFAIR to probe for causes and make a targeted plan for improvement. They want to think it’s just his fate, and he should be stuck with it.

    But in this day and age, high competence is needed just to get by in the world, especially if one expects to be a professional.

  7. trumwill says:

    What was particularly problematic about the situation with my grade school councilor is that if my parents had taken her advice, I would not have gotten my high school diploma. I would have gotten a “Certificate of Attendance” because I would have been exempted from the standardized test-taking required for a real diploma. (Exempting me from those tests, where I would have made the school look bad, was the point of the inquiry). I would have had to spend time in juco before going to a real university.

  8. trumwill says:

    Some people seem to have the idea that unless a kid is, what, catatonic or droolingly incoherent, it’s somehow UNFAIR to probe for causes and make a targeted plan for improvement. They want to think it’s just his fate, and he should be stuck with it.

    I think it goes back to the belief that if it’s mental, it’s psychological and you can beat it if you just summon up the willpower or you just want it bad enough. I don’t know if it’s a matter of believing they should be “stuck there” as it is that they should have to struggle to improve themselves. There’s kind of the mis-impression among normals that they have *earned* their degree of focus, their lack of dyslexia, their emotional stability, and so on. Forgetting the fact that they’re demanding that others struggle to achieve what may come naturally to them.

    But yeah, it’s just not fair that pharmaceuticals may be able to help someone achieve the level that genetics so fairly gave others. Genetics is fair. Drugs is cheating.

  9. Sheila Tone says:

    “See The Last Psychiatrist: “The Terrible, Awful Truth About Supplemental Security Income”. ”

    Hack, thank you for the link to a great article and a great blog.

  10. Peter says:

    SSDI, the payroll tax-funded program for working people who become disabled, is another bureaucratic morass. It takes at least a year to get benefits if everything goes without a hitch, and as you might expect things very seldom go without a hitch.

    I must admit that the slow processing of SSDI applications is not an entirely bad thing from my perspective. When giving sales presentations for disability insurance policies I mention this in an effort to persuade customers to take two-year policies rather than one-year policies … as you might expect, the longer policies pay higher commissions 🙂

  11. Mike Hunt says:

    Sheila Tone: I think whatever improves my kid’s performance should be done, especially if he’s below average.

    Since you don’t live in Lake Wobegon, half the children will be below average.

    My elementary school tried to put me in remedial-ed because I was “slow”. When I graduated from college, mom wanted to send the counseler a copy of my college degree.

    You already cited me for going over the line earlier this week. Well here it comes again. 1) After the check story, and after you got “counselor” wrong in two different ways in the replies, I am starting to think she might have a point. 2) From this post and from others, I think your mom has a screw loose.

    Sheila Tone: A lot of people seem to think it’s cheating or dishonest to do things to enhance one’s performance… But in this day and age, high competence is needed just to get by in the world, especially if one expects to be a professional.

    It is cheating to do things to enhance one’s performance. That is why sports organizations ban steroids and the like. Baseball recently banned “greenies” and there was a lower performance in day games played the day after night games. High competence is relative. People shouldn’t feel the need to take drugs to keep up with their co-workers. The threshold for prescribing these drugs should be VERY high. Only people who literally can’t function in society should get them.

  12. Mike Hunt says:

    -{This comment redacted by Trumwill}-

  13. Kirk says:

    For some reason the comment I made this morning has vanished. And I spent hours on it! (Not really.)

    Anyway, I wrote about the below article. It’s somewhat related, as it’s about psychiatric couselors making much ado about nothing just to cash a paycheck. (Or at least that’s my take on it. At least you gotta admit that it’s fascinating, how you can’t swing a dead cat at an upscale campus without finding someone who “needs” counseling.)

    And of course I love how they diagnose depression by asking people “have you ever felt hopeless?” Well, what if the person has a damn good reason for feeling that way?

    http://www.nytimes.com/2010/12/20/health/20campus.html?src=me&ref=health

  14. trumwill says:

    You already cited me for going over the line earlier this week.

    A statement prefaced with that probably means that you should not go on. Ditto for comments where you start off by pointing out a direction you know I don’t want to go and then going over everything I declined to mention and roundaboutly inserting it all anyway. That comment is redacted. Stop pushing the boundaries.

    It is cheating to do things to enhance one’s performance. That is why sports organizations ban steroids and the like. Baseball recently banned “greenies” and there was a lower performance in day games played the day after night games.

    Baseball is entertainment. Knock everyone down a peg and you’re not looking at much difference in terms of entertainment value because you merely have mildly less skillful hitters batting against mildly less skillful pitchers.

    Work, though, is different. Ever everyone gets knocked down a peg on their ability to do their job effectively, less things get done. There is objective rather than merely relative value to performance.

  15. trumwill says:

    Kirk, sorry. Comments where someone leaves a link are automatically put into the moderation queue. For some reason, I didn’t get the usual notice that something has been put there. So now both of your comments are up. Peter’s slipped through, too. I’ll have to look into that.

  16. Maria says:

    My dad would be considered “disabled” today as he had grand mal epilepsy. Yet he worked all of his life from childhood, and supported a large family without government help (with help from anti-seizure medicine).

    My daughter has ADD, takes Concerta, and is now an honor roll student. She is not “disabled.”

    How can you be ruled “disabled” if you take medicine that improves your condition?

    Just another stupid government giveaway.

  17. web says:

    Maria,

    If you are disabled enough unmedicated to be a burden on society (or upon a portion thereof), but are made functional by the application of said medication, then from a certain perspective society has an interest in your taking such medication – and thereby might have an interest in assisting you with paying for it. Likewise for someone who requires some form of therapy to function well in society.

    Yes, you are getting a “benefit.” From the perspective of society, society as a whole also gets a benefit: another productive member.

    Now, the question of whether ADD is overdiagnosed is harrowed at best. There are kids diagnosed “ADD” whose only crime is being bored stiff in school waiting for the “class moves at the pace of the slowest retard” classrooms to finally catch up to them. There are kids whose problem is not “ADD” but simply a lack of parenting that has left them with no concept of when the proper time to sit down, shut up, and behave themselves might be.

    And then there are kids where it’s a genuine neurological disorder who actually do need medication to function.

    The truth is somewhere in the middle. Is ADD overdiagnosed? Probably. Does society have a vested interest in assisting those who genuinely need the drugs to function well, with receiving them? Again, probably.

    And I have to believe that if ADD weren’t so overdiagnosed, then the bureaucracy administering SSI/SSDI might not be so bizarrely incoherent.

  18. Sheila Tone says:

    Everyone should read the SSI article to which Hack linked. It explains SSI as basically another welfare program for the population of people who tend to get other types of welfare.

    I would have been very opposed to this back in the day when I thought there were jobs available to everyone. I don’t think that anymore. Sure, most of my clients who get SSI for bipolar or personality disorders could “stack cans,” but who wants to hire them to do that? By and large, these are people that taxpayers don’t wish to work alongside or deal with in commerce.

  19. Sheila Tone says:

    “It is cheating to do things to enhance one’s performance. That is why sports organizations ban steroids and the like.”

    No, it’s because steroids are really bad for people.

  20. Sheila Tone says:

    And it is absolutely not a coincidence that the mother discussed in the Globe article is a career welfare mother, try as the writer does to make us relate to her.

  21. Sheila Tone says:

    Will, there’s no link to the GLob article above, so here it is: http://www.boston.com/news/local/massachusetts/articles/2010/12/12/with_ssi_program_a_legacy_of_unintended_side_effects/?page=2

    And the Globe article also has a quote describing SSI as “the new welfare.”

    “Of the 1.2 million low-income children nationwide who received SSI checks last year, 53 percent, or 640,000, qualified because of mental, learning, or behavioral issues, up from 8 percent in 1990. By significant margins, the top two disorders are Attention Deficit Hyperactivity Disorder, or ADHD, and delayed speech in young children, followed by autism spectrum disorders, bipolar illness, depression, and learning problems, according to the Social Security Administration, which runs this program and the $55 billion SSI system for adults.

    In New England, the numbers are even higher — 63 percent of children qualify for SSI based on such mental disabilities. That is the highest percentage for any region in the country. And here and across the nation, the SSI trend line is up, with children under 5 the fastest-growing group. Once diagnosed, these children often bring in close to half their family’s income.

    “This has become the new welfare,’’ said MIT economics professor David Autor. ”

    My god, that’s a huge change in just 20 years.

  22. Sheila Tone says:

    I’m trying to calculate how much of the increase in autism diagnoses could be attributable to the growth in SSI checks for autism.

  23. Maria says:

    If you are disabled enough unmedicated to be a burden on society (or upon a portion thereof), but are made functional by the application of said medication, then from a certain perspective society has an interest in your taking such medication – and thereby might have an interest in assisting you with paying for it.

    Web, ADD meds are not that expensive –$30 a month, something like that. Not “thousands of dollars a year.”

    If it’s a benefit for society, yeah, pay the $30 a month. Thousands of dollars per year is ridiculous.

    PS there are two types of ADD — the hyperactive kind, and the not paying attention kind. The hyperactive kind is more common in boys; the not paying attention kind is more common in girls. The girls are often not diagnosed because they are quiet and well-behaved — but they have troule reading, can’t organize their work, can’t remember their homework assignments, can’t read very well (a big one with my daughter), and often don’t pay attention to what they are doing.

    DNA researchers have recently found a gene that is associated with ADD, so it is real in some cases.

  24. Peter says:

    I’m trying to calculate how much of the increase in autism diagnoses could be attributable to the growth in SSI checks for autism.

    Isn’t most of the growth in autism diagnoses among the middle class and above?

  25. Sheila Tone says:

    OK, I read the whole Globe article, and I found no evidence that Geneva Fielding has worked a day in her life.

    “Nothing has come easily, least of all money.” Hogwash. It comes to her in the mail because she has kids. If it wasn’t SSI, it’d be welfare checks.

    Will, with all due respect, you kind of misled us about the real point of this article. It’s subtitled “The Other Welfare,” for crying out loud. It makes the same point Hack’s blog article makes, just in a more genteel fashion.

  26. Escapist says:

    I third the recommendation for the The Last Psychiatrist post on SSI.

    Regarding the idea in the article that SSI is needed to placate and keep the “unemployable” from running amok: bad guys are often irrational and will go to violence not in spite of your submission, but _because_ of it (it infuriates them and activates a predatory instinct). Perhaps this is because humans have a need for achievement, and getting something easily doesn’t satisfy it.

    As a former (briefly, but significantly) poor person, I agree with Maria: few people are truly so mentally and physically messed up that they couldn’t do some form of productive work. SSI etc enables borderline cases to veer off into slackdom/becoming more messed up, rather than getting it together to support themselves. It’s also a tremendous insult to those who are honest and work for that level of income.

    There’s a post/analysis at ZeroHedge along the lines that a savvy benefits user can end up with more disposable income than a mid-level working family.

  27. trumwill says:

    Sheila, I was commenting on the part of the article that interested me, which is how you would go about applying benefits to disorders that are not measurable. Not linking to the article was my bad, but it was an unintentional oversight.

  28. Sheila Tone says:

    Will, my point is that this blog post takes two very different issues and attempts to combine them as one. One issue: Do professional, responsible parents with resources abuse psychiatry to gain academic advantages for their children?

    Second issue: Do unproductive welfare cases such as Geneva Fielding abuse psychiatry to get more free money? That’s what the Globe article is about.

    I suspect Geneva Fielding is a lazy, irresponsible piece of crap, and I bristle at any attempt to cast my goals and hers in the same light.

  29. Sheila Tone says:

    “To get the check,’’ Fielding, 34, has concluded with regret, “you’ve got to medicate the child.’’

    There is nothing reflective, researched, or intellectual about welfare parents not liking psychotropic meds. They just don’t. They don’t like therapy, they don’t like psychiatry. Don’t like the doctors monkeying with their brains and telling them what and how to think. A kid can be schizophrenic, in long-term foster care because mom’s on meth, and yet meth mom will fill out the form opposing psychotropic meds JUST ‘CAUSE I DON’T TRUST THAT STUFF, with the most self-righteous attitude you ever saw.

    Jesus, I’m sickened by the reverent way this article treats that woman.

  30. Sheila Tone says:

    “God’s been good to me. If they cut me off, I’ll be all right,’’ says Fielding, who is active in parent and neighborhood groups.”

    Excuse me, Globe, what the hell does the second half of the sentence half to do with the first? Nothing, that’s what. You’re just desperately and unsuccessfully trying to rehabilitate your source.

    Sure you’ll be all right, Geneva — you’ll just go back on regular welfare.

  31. trumwill says:

    Hmmm… my commentary was primarily in reference to the second issue, but the two are connected by the focus of my interest, which is the immeasurability of these conditions. They are different issues in many other ways, though.

  32. Mike Hunt says:

    Work, though, is different. Ever everyone gets knocked down a peg on their ability to do their job effectively, less things get done. There is objective rather than merely relative value to performance.

    I disagree. Companies compete with each other. So, if everyone has their performance reduced, it wouldn’t hurt the companies’ ability to compete with each other. Remember, companies that provide coffee to their employees aren’t doing it to be nice. They feel the artifical increase in productivity outweighs the cost of the coffee. If greenies were legal and tasted good with milk and sugar, work would provide them as well.

    Sheila Tone: No, it’s because steroids are really bad for people.

    Fair enough, but I think the sports organization are concerned about a level playing field and not wanting to place athletes into the position to harm themselves in order to keep up. On the other hand, football doesn’t seem to concerned about players scrambling their brains due to concussions, and the IOC and TAC both band performance enhancing substances that aren’t necessarily bad for people.

    Not linking to the article was my bad, but it was an unintentional oversight.

    Yes, but it still isn’t linked. With Google and the like it probably doesn’t matter, but it seems suspicious that this is the article you don’t like to. Stop being such a wuss.

  33. trumwill says:

    Mike, I’ve been out of the state all day and it wasn’t brought to my attention until Sheila’s comment, where she provides the link. Commenting from my cell phone: Easy. Modifying posts on my cell phone: pain in the rear.

  34. Mike Hunt says:

    me: this is the article you don’t like to.

    I meant “link” to, not “like”. Sorry.

    Also, I didn’t see Sheila’s link, otherwise I wouldn’t have mentioned it. It still should have been linked to begin with. I will take you at your word that it was an oversight.

  35. Mike Hunt says:

    To those who were wondering, my redacted comment hit on the same themes Sheila did. I would imagine mine was redacted because Sheila is a VIP here, and my comment about Hit Coffee’s mom was perceived as being insulting. It’s fine, as long as the point got out.

    Regardless, to those I have annoyed or insulted in the past year, it was never personal. I hope all Hit Coffee readers have a happy holiday season.

  36. Sheila Tone says:

    “but it seems suspicious that this is the article you don’t like to. Stop being such a wuss.”

    Mike, you’re not a cunt. You’re an asshole. Cut it out.

    Will, I’m not really annoyed at you, I certainly don’t think you deliberately misled anyone or tried. Rather, I’m angered at the possibility of the public conflating my motive (greater productivity) with that of the Geneva Fieldings of the world (less productivity). Ironic, isn’t it?

  37. trumwill says:

    Mike, you know that I don’t like subjects to turn towards race, but you drew attention to Fielding’s race anyway. You know that I would prefer you not insult family members, but you lobbed the insult anyway.

    Had Sheila left either of these comments, she probably would have gotten an email saying that I would appreciate it if she would either rephrase what she said or avoid saying these sorts of things in the future. Leaving aside that I don’t have your email address (I’m not asking for it – I respect privacy concerns), you don’t seem to really care what I might or might not appreciate.

    So yes, you get different treatment than Sheila does.

  38. DaveinHackensack says:

    “Hack, thank you for the link to a great article and a great blog.”

    You’re welcome. Merry Xmas.

  39. Peter says:

    It’s easy to explain the rise in SSI cases: when regular (AFDC) welfare became more difficult to obtain, people went on SSI (and SSDI) instead.

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