HOUSE HEARING HIGHLIGHTS EXTREMES OF RITALIN CONTROVERSY

October 8, 2000

WASHINGTON -- The debate over the use of Ritalin and other psychotropic drugs to treat children with attention problems has been raging for years, but opinions remain sharply divided, as the House Education and Workforce Subcommittee on Oversight and Investigations found out recently. At a hearing called by Chairman Pete Hoekstra (R-Mich.), much of the debate centered on whether Attention Deficit/Hyperactivity Disorder, the primary target of these medications, even exists.

Valid Disorder or "Typical Behavior?"

Many pediatricians and other medical professionals argue AD/HD is a legitimate, treatable disorder. Others say it is simply a marketing tool for drug companies that is damaging children. "It is impossible to escape the conclusion that ADD/ADHD is a total fraud leading to the medical victimization of millions of previously normal, if troubled, mis-educated, children across the United States," neurologist Fred Baughman, of El Cajon, Calif., told the subcommittee.

Baughman particularly objects to the stigmatization of kids with AD/HD as "diseased."

"There can be no doubt here that they are calling ADD/ADHD a disease; the children abnormal, diseased," he said. "There is no physical or chemical abnormality to be found, in life or at autopsy, in 'depression, bipolar disorder and other mental illnesses.'" Therefore, he says, AD/HD should not be classified as a disease or treated as one.

Colorado State Board of Education member Patti Johnson (R-Broomfield) agrees. "The label of AD/HD is assigned if the child exhibits such symptoms as not listening when spoken to, is forgetful, fails to finish homework, fidgets, talks excessively, etc. -- the typical behavior of a normal child. Parents of children said to have these disorders are generally told that it is a neurological disorder or a chemical imbalance in the brain," Johnson said.

Some argue the diagnosis of AD/HD was developed as a response to children who do not conform to expectations in a structured classroom.

The American Psychiatric Association's 1994 Diagnostic and Statistical Manual of Mental Disorders lists three classifications of symptoms of AD/HD: hyperactivity, impulsivity and inattention. "Under hyperactivity, the first two, and most powerful, criteria are 'often fidgets with hands or feet or squirms in seat' and 'often leaves seat in classroom or in other situations in which remaining seated is expected,'" Bethesda, Md., physician Peter Breggin told the subcommittee. "Clearly, these two 'symptoms' are nothing more nor less than the behaviors most likely to cause disruptions in a large, structured classroom.

"Under impulsivity, the first criteria is 'often blurts out answers before questions have been completed,' and under inattention, the first criteria is 'often fails to give close attention to details or makes careless mistakes in schoolwork, work or other activities,'" he said. "Once again, the diagnosis itself, formulated over several decades, leaves no question concerning its purpose: to redefine disruptive classroom behavior into a disease. The ultimate aim is to justify the use of medication to suppress or control the behaviors."

Breggin is director of the Center for the Study of Psychiatry and Psychology and a medical consultant for the plaintiffs in two of the class actions pending against Novartis.

Proponents of AD/HD medications counter that medical research, while not as conclusive as researchers would like, shows enough evidence of a neurological disorder connected to the symptoms of AD/HD that medical professionals, educators and parents must take it seriously.

"AD/HD is not an easy diagnosis to make, and it's not a diagnosis that can be made in a five or 10 minute office visit," says David Fassler, a child and adolescent psychiatrist from Burlington, Vt. Speaking to the subcommittee on behalf of the American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry, Fassler said some symptoms of AD/HD are also common in other childhood problems, including anxiety disorders, depression and learning disabilities. "There is also a high degree of co-morbidity, meaning that over half the kids who have AD/HD also have a second significant psychiatric problem," he noted.

However, the APA's guidelines are more detailed and more rigorous than Breggin and his colleagues claim, Fassler said. "The diagnosis of ADHD requires a comprehensive assessment by a trained clinician. In addition to direct observation, the evaluation includes a review of the child's developmental, social, academic and medical history. It should also include input from the child's parents and teachers and a review of the child's records."

Medicating Kids vs. Improving Schools

The disorder carries significant consequences if ignored, Fassler added. "Without proper treatment, a child with AD/HD may fall behind in schoolwork and have problems at home or with friends. It can also have long-term effects on a child's self-esteem and lead to other problems in adolescence, including an increased risk of substance abuse."

Medication, administered through a "comprehensive and individualized" program, "can be extremely helpful for many children," Fassler said. "Medication alone is rarely the appropriate treatment for complex child psychiatric disorders such as AD/HD. Medication should only be used as part of a comprehensive treatment program, which will usually include individual therapy, family support and counseling and work with the schools."

Opponents of Ritalin and similar drugs argue the dangers of putting kids on medication outweigh the benefits. "Too often stimulants become gateway drugs to illicit drugs," Breggin told the subcommittee. "The use of prescription stimulants predisposes children to cocaine and nicotine abuse in young adulthood. Stimulants even more often become gateway drugs to additional psychiatric medications."

A better solution, Breggin and his colleagues argue, is to change the way children are taught.

Johnson, who plans to leave office when her term ends in January, pushed a resolution through the Colorado Board of Education last fall opposing the use of AD/HD drugs in schools. The resolution "promot[es] the use of academic solutions to resolve problems with behavior, attention and learning," Johnson told the subcommittee. "It reminded educators that their role was to teach and urged them to refrain from advising parents on medical matters."

The board also proposed that "funds currently used in the schools for treatment of the psychiatric learning disorders which have not been scientifically validated should be redirected into effective education programs such as after school tutoring," according to the text of the resolution. Whether the resolution was referring to state funds or federal money, which carries strict usage guidelines, is not clear.

Rep. Schaffer followed Johnson's lead last April, introducing House Resolution 459 to promote the use of "proven methods for behavior, attention and learning in school children." That resolution was referred to the House Education and the Workforce Subcommittee on Early Childhood, Youth and Families. Though it has garnered 24 co-sponsors, the measure is not expected to see any action from the subcommittee this Congressional term, since Congress will adjourn as soon as the remaining budget bills are passed.

In a statement released the day of the subcommittee hearing, Schaffer hinted at a connection between the provision of federal money for AD/HD students, through the Department of Education's IDEA budget and through the Social Security Administration's Supplemental Security Income program, and the broader corruption he has alleged exists in some federal spending programs. Schaffer and Hoekstra shepherded through the House a bill, H.R. 4079, to force a federal investigation of alleged Department of Education spending mistakes. That bill is awaiting action by the full Senate.

"I believe this is just the beginning, and I am confident our children will be better off if the correlation between financial public incentives and the frequency of psychotropic drug use among schoolchildren is more fully understood," Schaffer said.

While not commenting on the federal government's use of education funds, Breggin said he agrees reform efforts are inappropriately focused on the students instead of the schools. "By diagnosing and drugging our children, we shift blame for the problem from our social institutions and ourselves as adults to the relatively powerless children in our care. We harm our children by failing to identify and to meet their real educational needs for better prepared teachers, more teacher- and child-friendly classrooms, more inspiring curriculum and more engaging classroom technologies," Breggin said.

He argues schools regularly pressure and "coerce" parents into giving their children psychiatric medications. "Teachers, school psychologists and administrators commonly make dire threats about their inability to teach children without medicating them. They sometimes suggest that only medication can stave off a bleak future of delinquency and occupational failure."

Breggin claims some schools threaten to urge child protective services agencies to investigate parents for child neglect or testify against parents in court. In addition, he says, schools often point parents to physicians known to support the use of stimulants for children with behavior problems.

While the U.S. Department of Education does not take positions on the use of specific medications for any health conditions, Assistant Secretary for Special Education and Rehabilitative Services Judith Heumann noted her agency has made its position on the educator's role in this process clear. "It is not inappropriate for families to consult with educators in their decision-making process, but the diagnostic responsibilities and decisions must be left to physicians and families," Heumann told the subcommittee. "Educators can often provide input about the student's behavior that may aid in a diagnosis, but it is not the role of the school or the educator to make recommendations for treatment."

In addition, the Department of Education encourages the development of school-wide behavior management programs, she said. "We feel strongly that addressing behavioral problems should be a school-wide effort. There should be mutually understood behavioral expectations for all students. That is very important to ensuring that inappropriate behavior is responded to appropriately and effectively."

The Department of Education funds research and technical assistance projects to develop models for implementing positive behavioral support programs in schools, Heumann added.

Financial Incentive in IDEA?

But in other ways, the Department of Education and the federal special ed law it implements may be part of the alleged overmedication problem, opponents of medication say. "It is ... impossible to escape the conclusion that many departments, offices and officials of the federal government are, knowingly and unknowingly, parties to this fraud and victimization," Baughman said.

Taking a more aggressive stance, Colorado's Johnson argues the federal government should eliminate what she says is a financial incentive in the Individuals with Disabilities Education Act for schools to label children with learning disorders. After the Office of Special Education and Rehabilitative Services ruled in 1991 that a child with AD/HD qualifies for special education , Johnson claims, the rate of prescriptions for Ritalin and other AD/HD medications jumped dramatically. She believes the increased use of such medications is attributable to the promotion of them by educators and administrators, who are labeling more students as AD/HD so their schools will qualify for more federal special ed money.

By her interpretation of the Education for all Handicapped Children Act of 1975, IDEA's predecessor, Johnson says the original law was intended to ensure students with "physical disabilities" gain access to public education. "These children are now being shortchanged because such a large percentage of special education funds are being diverted to vague psychiatric diagnoses," Johnson told the subcommittee. "The so-called learning disorders have, sadly, become a way for financially strapped schools to make ends meet."

With IDEA, an expansion of the original special ed law, the likelihood of children being diagnosed with AD/HD has increased, Johnson claims. In addition to a broader definition of students with special needs to include those with non-physical disabilities, Johnson argues IDEA's "child-find" provision is increasing the number of children, particularly young children, who are ultimately placed on medication for attention problems. "Child-find" requires states to identify as many children as possible, in the first few years after birth, who may qualify for special education or early intervention services.

Debate Goes on

Shortly after the hearing, the National Alliance for the Mentally Ill issued a statement calling the testimony by the opponents of medication "skewed" and "inflammatory."

The hearing featured three witnesses arguing against the use of medication for AD/HD and only one in favor. The U.S. Surgeon General and the National Institute of Mental Health, which were specific targets of the medication opponents' criticisms, were not given a chance to state their positions, NAMI Executive Director Laurie Flynn said in a letter to Subcommittee Chairman Hoekstra. "The hearing offended me and thousands of other parents who conscientiously struggle to get diagnosis, treatment and support services for our children," she wrote. "Unfortunately, the largely one-sided rhetoric presented at the hearing serves primarily to scare or discourage parents who are seeking help for their kids. In that respect, it puts children at risk."8